Clinical Reasoning in the Health Professions [4th ed.] 9780702062247

Table of contents :
Title Page......Page 2
Table of Contents......Page 4
Copyright......Page 27
Preface......Page 29
The Context of Clinical Reasoning......Page 31
Collaborative and Transdisciplinary Reasoning......Page 32
Reasoning Across the Professions......Page 33
Teaching Clinical Reasoning......Page 34
Learning Clinical Reasoning......Page 35
List of Contributors......Page 37
Acknowledgements......Page 46
Section 1 Understanding Clinical Reasoning......Page 47
1 Clinical Reasoning......Page 48
Understanding Clinical Reasoning......Page 49
Challenges Faced by People Engaged in Clinical Decision Making......Page 51
Challenges of Dealing With a Complex World......Page 52
Challenges in Addressing Wicked Problems and Accountability......Page 54
Challenges of Making Complex and Consequential Decisions......Page 56
Challenges in Sharing Decision-Making Processes and Outcomes......Page 61
Building Clinical Reasoning Into Curricula......Page 62
Teaching and Learning Clinical Reasoning Complexities......Page 63
Learning Something That's Not Simply Black and White......Page 64
Chapter Summary......Page 65
References......Page 66
2 Re-Interpreting Clinical Reasoning......Page 70
Re-Interpreting Clinical Reasoning......Page 71
Clinical Reasoning as an Encultured Practice......Page 74
Understanding Professional Practice Paradigms......Page 80
Clinical Reasoning and Knowing in Practice......Page 87
Pursuing Clinical Reasoning Capability......Page 95
ReDefining Clinical Reasoning as A Range of Encultured Decision-Making Capabilities......Page 99
References......Page 105
3 Multiple Spaces of Choice, Engagement and Influence in Clinical Decision Making......Page 113
Clinical Reasoning Spaces From the Inside Out......Page 114
Client Spaces......Page 115
Practitioner Spaces......Page 117
The Collaborative Problem Space of the Team......Page 118
The Knowledge-Reasoning Space of Clinical Decision Making......Page 119
Errors......Page 120
Clinical Reasoning Strategies......Page 122
Professional Development of Clinical Reasoning Capability......Page 129
Chapter Summary......Page 133
References......Page 134
4 Clinical Reasoning and Models of Practice......Page 140
Recognizing Our Practice Context and Influences......Page 141
Models of Practice......Page 147
Reasoning in a Critical Social Science Model for Practice......Page 151
References......Page 160
5 The Development of Clinical Reasoning Expertise......Page 163
A Theory of the Development of Medical Expertise......Page 164
Teaching Clinical Reasoning......Page 171
Chapter Summary......Page 177
References......Page 178
6 Expertise and Clinical Reasoning......Page 183
Introduction......Page 184
Deconstructing the Interrelated Concepts of Expertise and Clinical Reasoning......Page 185
Expertise and Clinical Reasoning in Everyday Practice......Page 191
Clinical Reasoning and Novice Development: Developing Habits of Mind......Page 196
Chapter Summary......Page 199
References......Page 200
Section 2 The Changing Context of Clinical Reasoning and Practice......Page 205
7 The Context of Clinical Reasoning Across the Health Professions in the 21St Century......Page 206
Introduction......Page 207
Shifting Contexts and Identities......Page 210
Clinical Reasoning: Valuing Evidence......Page 213
Critical Reflexivity and ‘Negotiation’......Page 216
Chapter Summary......Page 217
References......Page 218
8 Changing Demographic and Cultural Dimensions of Populations......Page 223
Introduction......Page 224
Changing Populations......Page 226
Changing Populations and Clinical Reasoning......Page 228
Clinical Reasoning in a Postindustrial World......Page 238
Conclusion......Page 239
Chapter Summary......Page 240
References......Page 241
9 Clinical Thinking, Client Expectations and Patient-Centred Care......Page 244
Current Conceptions of Client Expectations and Patient-Centred Care......Page 245
How Healthcare Professionals Think: The Central Expertise of HCPs Needs to be Better Understood by Patients......Page 248
The Importance of the Nature of the HCP's Professionalism: Uncovering Its Transformative Potential......Page 252
Chapter Summary......Page 260
References......Page 261
10 Next-Generation Clinical Practice Guidelines......Page 266
Introduction......Page 267
Frameworks of Clinical Practice Guidelines Application......Page 268
Current State of Play in Clinical Practice Guidelines......Page 269
Critical Elements of Using Clinical Practice Guidelines......Page 270
Next-Generation Clinical Practice Guidelines......Page 272
Implementation......Page 273
Clinical Practice Guidelines, Clinical Reasoning and Patient Outcomes......Page 277
The Future......Page 279
Chapter Summary......Page 280
References......Page 281
11 Action and Narrative......Page 286
Action and Judgement......Page 287
Tacit Knowledge and Professional Judgement......Page 290
Narrative Reasoning......Page 292
Prospective Stories: Therapy and Life Stories......Page 294
Active Judgements, Tacit Knowledge and Narrative Images: a Case Story......Page 297
Action, Judgement, Narrative and Expertise in Ann's Story......Page 299
Chapter Summary......Page 302
References......Page 303
12 The Language of Clinical Reasoning......Page 306
Introduction......Page 307
Metaphor......Page 309
New Metaphors in Clinical Reasoning......Page 312
Narrative......Page 314
Rhetoric......Page 315
Chapter Summary......Page 318
References......Page 319
13 Evidence-Based Practice and Clinical Reasoning......Page 322
Introduction......Page 323
Section 1: Evidence-Based Practice Is a Contributor to Clinical Reasoning......Page 327
Section 2: Evidence-Based Practice Is the Way in Which Clinical Reasoning Unfolds or Should Unfold......Page 332
Section 3: Evidence-Based Practice and Clinical Reasoning Are Different Words/Frames for the ‘Same Thing’......Page 337
References......Page 340
14 Methods in the Study of Clinical Reasoning......Page 345
Introduction......Page 346
Quantitative Methods......Page 347
Qualitative Methods......Page 352
Conclusion......Page 358
Chapter Summary......Page 359
References......Page 360
Section 3 Collaborative and Transdisciplinary Reasoning......Page 366
15 Collaborative Decision Making in Liquid Times......Page 367
New Conditions of Decision-Making Processes in Liquid Times......Page 368
Conceptual Perspectives and Principles of Collaborative Decision Making......Page 372
Conceptual Models of Shared Decision Making......Page 374
The Primacy of Interests: a Critical Model for Collaborative Decision Making......Page 375
Operationalizing Collaborative Decision Making......Page 378
References......Page 385
16 Ethical Reasoning......Page 388
Introduction......Page 389
The Ethical Reasoning Bridge......Page 392
Chapter Summary......Page 404
References......Page 405
17 Shared Decision Making in Practice......Page 410
Shared Decision Making......Page 411
Chapter Summary......Page 425
References......Page 426
18 Using Decision Aids to Involve Clients in Clinical Decision Making......Page 432
Introduction......Page 433
What Is A Patient Decision Aid?......Page 434
When Should You Consider Using a Decision Aid?......Page 435
How Do Decision Aids Work?......Page 438
What Makes a ‘Good’ Decision Aid?......Page 439
Where Can You Find Patient Decision Aids?......Page 442
What Should I Do if I Cannot Find a Relevant Decision Aid?......Page 443
How Can the Health Team Play a Role?......Page 444
Can Patient Decision Aids Be Used to Involve Family Members and Carers?......Page 445
Can Patients From Vulnerable Populations Benefit From Using Patient Decision Aids?......Page 446
Chapter Summary......Page 447
References......Page 448
19 Clinical Decision Making, Social Justice and Client empowerment......Page 454
Introduction......Page 455
Social Determinants of Health......Page 456
Social Justice......Page 461
Empowerment......Page 467
Chapter Summary......Page 469
References......Page 470
20 Clinical Decision Making Across Orthodox and Complementary Medicine Fields......Page 475
Introduction......Page 476
Alternative Ways of Thinking Through Clinical Problems......Page 479
Models of Integration......Page 483
Integrated Clinical Reasoning......Page 486
Chapter Summary......Page 489
References......Page 490
Section 4 Clinical Reasoning and The Professions......Page 495
21 Clinical Reasoning in Medicine......Page 496
Introduction......Page 497
A Common Basis: Dual-Process Theory......Page 498
Problem Solving: Diagnosis as Hypotheses Generation and Selection......Page 499
The Hypothetico-Deductive Method......Page 500
Diagnosis as Categorization or Pattern Recognition......Page 502
Multiple Reasoning Strategies......Page 503
Decision Making: Diagnosis as Opinion Revision......Page 504
A Common Challenge: Diagnostic Error......Page 506
Errors in Hypothesis Generation and Restructuring......Page 507
Errors in Data Interpretation......Page 508
Errors in Probability Estimation......Page 509
Errors in Probability Revision......Page 510
Educational Implications......Page 512
Problem Solving: Educational Implications......Page 513
Decision Making: Educational Implications......Page 514
References......Page 517
22 Clinical Reasoning in Nursing......Page 526
Introduction......Page 527
Theoretical Perspectives......Page 528
Chapter Summary......Page 545
References......Page 546
23 Clinical Reasoning in Physiotherapy......Page 552
Introduction......Page 553
Why Do Physiotherapists Need to Study and Practice Clinical Reasoning?......Page 554
Three Frameworks to Situate Clinical Reasoning in Physiotherapy......Page 559
Factors Influencing Clinical Reasoning......Page 571
References......Page 578
24 Clinical Reasoning in Dentistry......Page 586
Evolution of Clinical Reasoning......Page 587
Exploring Clinical Reasoning......Page 588
Conceptual Framework......Page 590
Processes of Clinical Reasoning......Page 591
Clinical Reasoning Strategies......Page 593
Uncertainties in Clinical Reasoning......Page 596
Assessment of Clinical Reasoning......Page 599
Chapter Summary......Page 600
References......Page 601
25 Clinical Reasoning in Occupational Therapy......Page 608
Introduction......Page 609
Clinical Reasoning in Occupational Therapy: Historical Perspective......Page 610
Knowledge and Clinical Reasoning in Occupational Therapy......Page 613
Information Processing, Cognitive Strategy Use and Clinical Reasoning......Page 622
Chapter Summary......Page 629
References......Page 630
26 Clinical Decision Making in Emergency Medicine......Page 637
Introduction......Page 638
Emergence of Dual-Process Theory in Clinical Decision Making......Page 639
Rationality in Clinical Decision Making......Page 641
Facilitators of Rationality......Page 642
Dysrationalia......Page 644
How Does CDM in Emergency Medicine Differ From That in Other Settings?......Page 652
References......Page 653
27 Clinical Decision Making in Paramedicine......Page 657
Introduction......Page 658
The Nature of Paramedic Practice......Page 659
Clinical Reasoning in Paramedicine Practice......Page 661
Cognitive Strategies Involved in Clinical Reasoning......Page 662
Errors in Clinical Reasoning......Page 664
Educational Strategies to Improve Clinical Reasoning......Page 666
Chapter Summary......Page 669
References......Page 670
28 Clinical Decision Making in Optometry......Page 673
Optometry and Its Scope of Practice......Page 674
Evidence-Based Decision Making in Optometry......Page 676
From Decision Making to Clinical Reasoning......Page 684
Conclusion......Page 687
Chapter Summary......Page 688
References......Page 689
29 Clinical Reasoning in Dietetics......Page 694
Introduction......Page 695
The Context of Dietetics......Page 696
Clinical Reasoning in Clinical Dietetics......Page 699
Collaborative Decision Making in Dietetics......Page 704
Clinical Reasoning in Advanced Dietetic Practice......Page 706
Chapter Summary......Page 710
References......Page 711
30 Clinical Reasoning in Pharmacy......Page 715
Introduction......Page 716
The Pharmacist as Part of A Collaborative Team......Page 717
Clinical Problem Solving for the Pharmacist......Page 718
Chapter Summary......Page 731
References......Page 732
Section 5 Teaching Clinical Reasoning......Page 734
31 Pedagogies for Teaching and Learning Clinical Reasoning......Page 735
What Is Clinical Reasoning?......Page 736
Embodied Nature of Clinical Reasoning......Page 738
Situated Nature of Clinical Reasoning......Page 740
Pedagogies for Teaching Clinical Reasoning......Page 741
Teaching Clinical Reasoning in Classrooms......Page 744
Teaching Clinical Reasoning in Workplaces......Page 746
Future Directions......Page 750
Chapter Summary......Page 752
References......Page 753
32 Teaching Clinical Reasoning in Medical Education Courses......Page 757
Introduction......Page 758
Understanding Reasoning......Page 759
Integration......Page 770
Introduction to Uncertainty and Diagnostic Error......Page 778
Conclusion......Page 784
References......Page 785
33 Teaching Clinical Reasoning in Nursing Education......Page 790
Providing Opportunities for Autonomous Practice......Page 791
Focussing on Deliberate Practice......Page 792
Using Higher-Order Questioning......Page 793
Emphasizing the Importance of Evidence-Based Practice......Page 795
Learning to Think Aloud......Page 796
Deconstructing Critical Events......Page 798
Reflecting on Cognitive Biases......Page 799
Chapter Summary......Page 803
References......Page 804
34 Speech-Language Pathology Students......Page 807
Introduction......Page 808
ICF as a Framework for Clinical Reasoning......Page 810
Facilitating Clinical Reasoning......Page 813
Clinical Reasoning Approaches......Page 814
ICF and Clinical Reasoning in Practice (Case Study 34.1 Analysis)......Page 817
Strong Clinical Reasoning Includes Consideration of All Areas of ICF (Case Study 34.2 Analysis)......Page 819
Strategies for Ces: Using the ICF to Extend Students’ Clinical Reasoning Skills......Page 820
Chapter Summary......Page 823
Acknowledgement......Page 824
References......Page 825
35 Clinical Reasoning and Biomedical Knowledge......Page 828
Introduction......Page 829
Curricular and Epistemological Issues......Page 830
Research in Clinical Reasoning......Page 832
Knowledge Encapsulation or Two Worlds......Page 839
Chapter Summary......Page 843
References......Page 844
36 Cultivating A Thinking Surgeon, Using A Clinical Thinking Pathway as A Learning and Assessment Process......Page 849
Introduction......Page 850
The Clinical Thinking Pathway: the Basic Components......Page 851
Key Insights From 10 Years of Work......Page 856
Crystallizing the Discourse and Offering Further Educational Resources......Page 859
Chapter Summary......Page 865
References......Page 867
37 Interprofessional Programs to Develop Clinical Reasoning......Page 872
Introduction......Page 873
Background......Page 874
Learning Outcomes......Page 875
Interprofessional Learning Activities for Clinical Reasoning......Page 876
Learning Through Structured Opportunities in the Classroom......Page 877
Learning Through Simulation......Page 878
Learning Through Community Engagement, Partnerships and Service......Page 879
Learning About Collaborative Leadership......Page 882
Challenges of IPE......Page 884
Faculty Development......Page 885
Chapter Summary......Page 887
References......Page 888
38 Assessing Clinical Reasoning......Page 892
Introduction......Page 893
Research on Decision Making......Page 895
An Historical Perspective on Assessment......Page 896
Newer Assessment Developments......Page 898
But What About Clinical Reasoning?......Page 901
Current Developments......Page 903
Implications and Advice for the Teacher......Page 904
References......Page 906
Section 6 Learning Clinical Reasoning......Page 911
39 Learning to Communicate Clinical Reasoning......Page 912
Introduction......Page 913
Communication of Clinical Reasoning......Page 914
Learning to Communicate Clinical Reasoning: What's Involved?......Page 916
Chapter Summary......Page 923
References......Page 924
40 Developing Clinical Reasoning Capability......Page 927
Capability as A Learning Outcome......Page 928
Clinical Reasoning Capability......Page 930
Future Implications......Page 936
Chapter Summary......Page 938
References......Page 939
41 Remediating Learning and Performance of Reasoning......Page 944
Can Clinical Reasoning Be Learned?......Page 945
Identification of Students Who Struggle With Clinical Reasoning......Page 946
Understanding Struggling Learners......Page 948
Unique Challenges to Learning Clinical Reasoning......Page 950
An Approach to the Remediation of Clinical Reasoning......Page 951
Using the Tools and Grids in the Clinical Environment......Page 958
Chapter Summary......Page 960
References......Page 961
42 Learning About Factors Influencing Clinical Decision Making......Page 963
Clinical Decision Making......Page 964
Acknowledgement......Page 978
References......Page 979
43 Learning Reasoning Using Simulation......Page 981
Introduction......Page 982
What Is Simulation-Based Learning?......Page 983
Facilitating Clinical Reasoning Development Through Simulation-Based Learning......Page 989
Cognitive Load Considerations for Simulation-Based Learning......Page 993
Future Implications......Page 997
Chapter Summary......Page 998
References......Page 999
44 Learning to Use Evidence to Support Decision Making......Page 1003
Understanding Evidence-Based Practice......Page 1004
What Constitutes Evidence?......Page 1007
Evidence-Based Practice and Clinical Reasoning......Page 1014
References......Page 1020
45 Learning to Research Clinical Reasoning......Page 1024
Introduction......Page 1025
Develop a Research Question......Page 1026
Identify a Conceptual Framework......Page 1027
Select the Research Designs and Methods......Page 1030
Develop the Research Design......Page 1033
Chapter Summary......Page 1038
References......Page 1039
46 Learning Clinical Reasoning Across Cultural Contexts......Page 1041
Introduction......Page 1042
Culture, Context and Professional Practice......Page 1043
What Is Cultural Competence?......Page 1045
Conclusion......Page 1053
References......Page 1054
47 Peer Learning to Develop Clinical Reasoning Abilities......Page 1057
Peer Learning for Knowledge and Metaskills Development......Page 1058
Peer Learning Activity Design Considerations......Page 1059
Facilitating Clinical Reasoning Development With Peer Learning......Page 1062
Conclusion......Page 1068
References......Page 1069
Index......Page 1072

Citation preview

Clinical Reasoning in the Health Professions FOURTH EDITION

EDITED BY

Joy Higgs, AM, PhD, MHPEd, BSc, PFHEA Professor in Higher Education, Charles Sturt University, Sydney, Australia

Gail M. Jensen, PhD, PT, FAPTA Professor of Physical Therapy,

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Faculty Associate, Center for Health Policy and Ethics, Dean, Graduate School, Vice Provost for Learning and Assessment, Creighton University, Omaha, Nebraska, USA

Stephen Loftus, PhD, MSc, BDS Associate Professor of Medical Education, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA

Nicole Christensen, PhD, MAppSc, BS, BA Professor and Chair, Department of Physical Therapy, Samuel Merritt University, Oakland, California, USA

Edinburgh London New York Oxford Philadelphia St. Louis Sydney 2019

3

Table of Contents Cover image Title Page Copyright Preface Clinical Reasoning as the Core of Professional Practice The Context of Clinical Reasoning Collaborative and Transdisciplinary Reasoning Reasoning Across the Professions Teaching Clinical Reasoning Learning Clinical Reasoning List of Contributors Acknowledgements

4

Section 1 Understanding Clinical Reasoning 1 Clinical Reasoning Understanding Clinical Reasoning Challenges Faced by People Engaged in Clinical Decision Making Challenges of Dealing With a Complex World Challenges in Addressing Wicked Problems and Accountability Challenges of Making Complex and Consequential Decisions Challenges in Sharing Decision-Making Processes and Outcomes Challenges Faced by People Engaged in Learning and Teaching Clinical Reasoning Building Clinical Reasoning Into Curricula Teaching and Learning Clinical Reasoning Complexities Learning Something That's Not Simply Black and White Chapter Summary References 2 Re-Interpreting Clinical Reasoning Re-Interpreting Clinical Reasoning Clinical Reasoning as an Encultured Practice Understanding Professional Practice Paradigms Clinical Reasoning and Knowing in Practice

5

Pursuing Clinical Reasoning Capability ReDefining Clinical Reasoning as A Range of Encultured Decision-Making Capabilities Chapter Summary References 3 Multiple Spaces of Choice, Engagement and Influence in Clinical Decision Making Introduction Clinical Reasoning Spaces From the Inside Out Client Spaces Practitioner Spaces The Collaborative Problem Space of the Team The Problem Space of the Workplace and the Local System The Knowledge-Reasoning Space of Clinical Decision Making The Problem Space of the Global Health Care System With Its Discourse, Knowledge and Technology Errors Clinical Reasoning Strategies Professional Development of Clinical Reasoning Capability Chapter Summary References 4 Clinical Reasoning and Models of Practice

6

Introduction Recognizing Our Practice Context and Influences Models of Practice Reasoning in a Critical Social Science Model for Practice Chapter Summary References 5 The Development of Clinical Reasoning Expertise Introduction A Theory of the Development of Medical Expertise Teaching Clinical Reasoning Chapter Summary References 6 Expertise and Clinical Reasoning Introduction Deconstructing the Interrelated Concepts of Expertise and Clinical Reasoning Expertise and Clinical Reasoning in Everyday Practice Clinical Reasoning and Novice Development: Developing Habits of Mind Chapter Summary References

7

Section 2 The Changing Context of Clinical Reasoning and Practice 7 The Context of Clinical Reasoning Across the Health Professions in the 21St Century Introduction Shifting Contexts and Identities Clinical Reasoning: Valuing Evidence Critical Reflexivity and ‘Negotiation’ Chapter Summary References 8 Changing Demographic and Cultural Dimensions of Populations Introduction Changing Populations Changing Populations and Clinical Reasoning Clinical Reasoning in a Postindustrial World Conclusion Chapter Summary References 9 Clinical Thinking, Client Expectations and Patient-Centred Care Introduction Current Conceptions of Client Expectations and Patient-

8

Centred Care How Healthcare Professionals Think: The Central Expertise of HCPs Needs to be Better Understood by Patients The Importance of the Nature of the HCP's Professionalism: Uncovering Its Transformative Potential Chapter Summary References 10 Next-Generation Clinical Practice Guidelines Introduction Frameworks of Clinical Practice Guidelines Application Current State of Play in Clinical Practice Guidelines Critical Elements of Using Clinical Practice Guidelines Next-Generation Clinical Practice Guidelines Implementation Consumer Engagement Clinical Practice Guidelines, Clinical Reasoning and Patient Outcomes The Future Chapter Summary References 11 Action and Narrative Introduction

9

Action and Judgement Tacit Knowledge and Professional Judgement Narrative Reasoning Prospective Stories: Therapy and Life Stories Active Judgements, Tacit Knowledge and Narrative Images: a Case Story Action, Judgement, Narrative and Expertise in Ann's Story Chapter Summary References 12 The Language of Clinical Reasoning Introduction Metaphor New Metaphors in Clinical Reasoning Narrative Rhetoric Chapter Summary References 13 Evidence-Based Practice and Clinical Reasoning Introduction Section 1: Evidence-Based Practice Is a Contributor to Clinical Reasoning Section 2: Evidence-Based Practice Is the Way in Which

10

Clinical Reasoning Unfolds or Should Unfold Section 3: Evidence-Based Practice and Clinical Reasoning Are Different Words/Frames for the ‘Same Thing’ Chapter Summary References 14 Methods in the Study of Clinical Reasoning Introduction Quantitative Methods Qualitative Methods Conclusion Chapter Summary References

Section 3 Collaborative and Transdisciplinary Reasoning 15 Collaborative Decision Making in Liquid Times Introduction New Conditions of Decision-Making Processes in Liquid Times Conceptual Perspectives and Principles of Collaborative Decision Making Conceptual Models of Shared Decision Making The Primacy of Interests: a Critical Model for Collaborative

11

Decision Making Operationalizing Collaborative Decision Making Chapter Summary References 16 Ethical Reasoning Introduction The Ethical Reasoning Bridge Chapter Summary References 17 Shared Decision Making in Practice Introduction Shared Decision Making Chapter Summary References 18 Using Decision Aids to Involve Clients in Clinical Decision Making Introduction What Is A Patient Decision Aid? When Should You Consider Using a Decision Aid? How Do Decision Aids Work? What Makes a ‘Good’ Decision Aid?

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Where Can You Find Patient Decision Aids? What Is the Best Way to Involve Clients in Using Decision Aids? What Should I Do if I Cannot Find a Relevant Decision Aid? How Can the Health Team Play a Role? Can Patient Decision Aids Be Used to Involve Family Members and Carers? Can Patients From Vulnerable Populations Benefit From Using Patient Decision Aids? Chapter Summary References 19 Clinical Decision Making, Social Justice and Client empowerment Introduction Social Determinants of Health Social Justice Empowerment Chapter Summary References 20 Clinical Decision Making Across Orthodox and Complementary Medicine Fields Introduction Alternative Ways of Thinking Through Clinical Problems

13

Integrating Alternative Ways of Thinking With the Thinking of Mainstream Allopathic Medicine Models of Integration Integrated Clinical Reasoning Chapter Summary References

Section 4 Clinical Reasoning and The Professions 21 Clinical Reasoning in Medicine Introduction A Common Basis: Dual-Process Theory Problem Solving: Diagnosis as Hypotheses Generation and Selection The Hypothetico-Deductive Method Diagnosis as Categorization or Pattern Recognition Multiple Reasoning Strategies Decision Making: Diagnosis as Opinion Revision A Common Challenge: Diagnostic Error Errors in Hypothesis Generation and Restructuring Errors in Data Interpretation Errors in Probability Estimation Errors in Probability Revision

14

Educational Implications Problem Solving: Educational Implications Decision Making: Educational Implications Chapter Summary References 22 Clinical Reasoning in Nursing Introduction Definition of Clinical Reasoning Theoretical Perspectives Chapter Summary References 23 Clinical Reasoning in Physiotherapy Introduction Why Do Physiotherapists Need to Study and Practice Clinical Reasoning? Three Frameworks to Situate Clinical Reasoning in Physiotherapy Factors Influencing Clinical Reasoning Chapter Summary References 24 Clinical Reasoning in Dentistry

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Evolution of Clinical Reasoning Exploring Clinical Reasoning Conceptual Framework Processes of Clinical Reasoning Clinical Reasoning Strategies Key Features in Clinical Reasoning of Dentists Uncertainties in Clinical Reasoning Assessment of Clinical Reasoning Chapter Summary References 25 Clinical Reasoning in Occupational Therapy Introduction Clinical Reasoning in Occupational Therapy: Historical Perspective Knowledge and Clinical Reasoning in Occupational Therapy Information Processing, Cognitive Strategy Use and Clinical Reasoning Chapter Summary References 26 Clinical Decision Making in Emergency Medicine Introduction Emergence of Dual-Process Theory in Clinical Decision Making

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Rationality in Clinical Decision Making Facilitators of Rationality Dysrationalia How Does CDM in Emergency Medicine Differ From That in Other Settings? Chapter Summary References 27 Clinical Decision Making in Paramedicine Introduction The Nature of Paramedic Practice Clinical Reasoning in Paramedicine Practice Cognitive Strategies Involved in Clinical Reasoning Errors in Clinical Reasoning Educational Strategies to Improve Clinical Reasoning Chapter Summary References 28 Clinical Decision Making in Optometry Optometry and Its Scope of Practice Evidence-Based Decision Making in Optometry From Decision Making to Clinical Reasoning Conclusion

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Chapter Summary References 29 Clinical Reasoning in Dietetics Introduction The Context of Dietetics Clinical Reasoning in Clinical Dietetics Collaborative Decision Making in Dietetics Clinical Reasoning in Advanced Dietetic Practice Chapter Summary References 30 Clinical Reasoning in Pharmacy Introduction The Pharmacist as Part of A Collaborative Team Clinical Problem Solving for the Pharmacist Chapter Summary References

Section 5 Teaching Clinical Reasoning 31 Pedagogies for Teaching and Learning Clinical Reasoning What Is Clinical Reasoning?

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Embodied Nature of Clinical Reasoning Situated Nature of Clinical Reasoning Pedagogies for Teaching Clinical Reasoning Teaching Clinical Reasoning in Classrooms Teaching Clinical Reasoning in Workplaces Future Directions Chapter Summary References 32 Teaching Clinical Reasoning in Medical Education Courses Introduction Understanding Reasoning Integration Introduction to Uncertainty and Diagnostic Error Conclusion Chapter Summary References 33 Teaching Clinical Reasoning in Nursing Education Introduction Providing Opportunities for Autonomous Practice Focussing on Deliberate Practice Using Higher-Order Questioning

19

Emphasizing the Importance of Evidence-Based Practice Learning to Think Aloud Deconstructing Critical Events Reflecting on Cognitive Biases Chapter Summary References 34 Speech-Language Pathology Students Introduction ICF as a Framework for Clinical Reasoning Facilitating Clinical Reasoning Clinical Reasoning Approaches ICF and Clinical Reasoning in Practice (Case Study 34.1 Analysis) Strong Clinical Reasoning Includes Consideration of All Areas of ICF (Case Study 34.2 Analysis) Strategies for Ces: Using the ICF to Extend Students’ Clinical Reasoning Skills Chapter Summary Acknowledgement References 35 Clinical Reasoning and Biomedical Knowledge Introduction

20

Curricular and Epistemological Issues Research in Clinical Reasoning Knowledge Encapsulation or Two Worlds Chapter Summary References 36 Cultivating A Thinking Surgeon, Using A Clinical Thinking Pathway as A Learning and Assessment Process Introduction The Clinical Thinking Pathway: the Basic Components Key Insights From 10 Years of Work Crystallizing the Discourse and Offering Further Educational Resources Chapter Summary References 37 Interprofessional Programs to Develop Clinical Reasoning Introduction Background Learning Outcomes Interprofessional Learning Activities for Clinical Reasoning Learning Through Structured Opportunities in the Classroom Learning Through Simulation Learning Through Community Engagement, Partnerships and

21

Service Learning About Collaborative Leadership Challenges of IPE Faculty Development Chapter Summary References 38 Assessing Clinical Reasoning Introduction Research on Decision Making An Historical Perspective on Assessment Newer Assessment Developments But What About Clinical Reasoning? Current Developments Gaps and Remedies Implications and Advice for the Teacher Chapter Summary References

Section 6 Learning Clinical Reasoning 39 Learning to Communicate Clinical Reasoning Introduction

22

Communication of Clinical Reasoning Learning to Communicate Clinical Reasoning: What's Involved? Chapter Summary References 40 Developing Clinical Reasoning Capability Introduction Capability as A Learning Outcome Clinical Reasoning Capability Facilitating Clinical Reasoning Capability and Adaptive Expertise Future Implications Chapter Summary References 41 Remediating Learning and Performance of Reasoning Can Clinical Reasoning Be Learned? Identification of Students Who Struggle With Clinical Reasoning Understanding Struggling Learners Unique Challenges to Learning Clinical Reasoning An Approach to the Remediation of Clinical Reasoning Using the Tools and Grids in the Clinical Environment Chapter Summary

23

References 42 Learning About Factors Influencing Clinical Decision Making Introduction Clinical Decision Making Chapter Summary Acknowledgement References 43 Learning Reasoning Using Simulation Introduction What Is Simulation-Based Learning? Facilitating Clinical Reasoning Development Through Simulation-Based Learning Cognitive Load Considerations for Simulation-Based Learning Future Implications Chapter Summary References 44 Learning to Use Evidence to Support Decision Making Introduction Understanding Evidence-Based Practice What Constitutes Evidence? Evidence-Based Practice and Clinical Reasoning

24

Chapter Summary References 45 Learning to Research Clinical Reasoning Introduction Develop a Research Question Identify a Conceptual Framework Select the Research Designs and Methods Develop the Research Design Conclusion Chapter Summary References 46 Learning Clinical Reasoning Across Cultural Contexts Introduction Professional Culture and Language Culture, Context and Professional Practice What Is Cultural Competence? Conclusion Chapter Summary References 47 Peer Learning to Develop Clinical Reasoning Abilities

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Introduction Peer Learning for Knowledge and Metaskills Development Peer Learning Activity Design Considerations Facilitating Clinical Reasoning Development With Peer Learning Conclusion Chapter Summary References Index

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Copyright © 2019, Elsevier Limited. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1995 Second edition 2000 Third edition 2008 Fourth edition 2019 ISBN: 978–0-7020–6224–7

Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein.

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Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Content Strategist: Poppy Garraway, Serena Castelnovo Content Development Specialist: Helen Leng Project Manager: Manchu Mohan Design: Patrick Ferguson Illustration Manager: Teresa McBryan Illustrator: Muthukumaran Thangaraj

Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

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Preface In earlier editions of this book we sought out scholars, educators and practitioners who were examining the challenges of clinical reasoning and decision making. Each edition expanded our understanding of what clinical reasoning is across the professions and how these changes in reasoning approaches are shaping both professional practice changes and how practice developments are influencing changes in clinical reasoning. The fourth edition of this book has been written to reflect these current and emerging developments in an age of digital communication and cultural and socioeconomic changes in professional practice and society. These changes include increased commodification and globalization of health services and greater expectations by consumers of their rights to share decision making about their health care. This book sets out to examine all aspects of the complex phenomenon of clinical reasoning across six areas of consideration: 1. Understanding clinical reasoning 2. The changing context of clinical reasoning and practice 3. Collaborative and transdisciplinary reasoning 4. Clinical reasoning and the professions 5. Teaching clinical reasoning 6. Learning clinical reasoning. Key themes presented in the fourth edition are:

▪ Clinical reasoning as a composite of encultured capabilities 29

▪ Clinical reasoning embedded within situated practice, including the wider socioeconomic and political contexts, the practitioner's and the client's contexts and shared goals such as promoting health communities ▪ Clinical reasoning and practice models of knowledge-culture and practice problem spaces ▪ The importance of narratives, language and culture in clinical decision making ▪ The idea of practitioners particularly (and also clients) as perpetual learners, continually expanding their knowledge base, critically appraising their reasoning abilities and enhancing their reasoning capabilities ▪ Changing reasoning practices linked to increasing autonomy of practitioners working without the requirement of medical referrals ▪ Clinical reasoning as an increasingly team-based practice, including shared decision making with clients ▪ The need for sound strategies and tools to facilitate the expanding collaborations in health care across disciplines and with clients and carers ▪ Advanced education approaches promoting expansion and enhancement of reasoning strategies ▪ The importance of building good practices for learning clinical reasoning into curricula and into students' own practice development approaches ▪ Strengthening links between orthodox and complementary medicine reasoning practices. 30

Clinical Reasoning as the Core of Professional Practice Professional decision making (often labelled clinical reasoning in clinical contexts) is the core competency of professional practice. In this book we focus on clinical reasoning, while recognizing that many of the practices and educational strategies discussed relate to health care in other settings such as schools. Without the capacity to make sound, client-centred clinical decisions, health practitioners cannot capably perform professional practice or best serve the interests of their patients, clients and communities. In reexamining the nature of clinical reasoning in this edition, authors examined (see Chapter 1) the way professional decision making is changing in relation to changes in the world of clinical practice in this century. Chapter 2 introduces the notion of epistemic cultures and decision making in practice paradigms and presents clinical reasoning as a model of encultured decisionmaking practice capabilities. Section 1 also examines key aspects of clinical reasoning through the ideas of clinical problem spaces, clinical practice models and links between reasoning and practice expertise.

The Context of Clinical Reasoning Section 2 of the book provides the reader with insights into the dynamic contextual environment that is influencing evolving practices of clinical reasoning and decision making. In the fourth edition of Clinical Reasoning in the Health Professions, this changing context is envisioned through examination of several environmental factors such as changing demographics, high client expectations, evolving technology, increasing globalization and continued commercialization of healthcare delivery. The context of clinical reasoning is changing for all health professionals. Health professionals are working, in many countries, with an aging population. With increased life expectancy comes the growth of noncommunicable, chronic diseases. Managing chronic health conditions brings new forms of complexity to clinical care not only from comorbidities but also from the need for the funding of health

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care and long-term care. Increasing ethnic and racial diversity is occurring across many countries, and with this comes the challenge for practitioners to formulate a treatment plan that fits patients' personal values and cultural customs. Health care as a sizeable component in many countries' economies is now part of continued commercialization and privatization of healthcare delivery. Health professionals must navigate these economic influences in their clinical reasoning and decision-making process. Organizational and regulatory pressures for evidence of patient-centred care, coupled with the power of social media and patient access to health information, add another layer of complexity to health professionals' clinical reasoning processes. In addition, technology and the explosive growth of big data across many organizations bring an additional layer of evidence that health professionals must consider in clinical decision making. As healthcare practice occurs in an increasingly complex, diverse and uncertain environment, how clinical reasoning is envisioned, enacted and investigated through models of practice is also evolving. Importantly, investigative methods for studying clinical reasoning also must evolve. The interdependence of clinical reasoning and clinical practice needs to remain central to both practice and research. Practitioners must engage in a critical practice model that maintains a critical view of current practices along with continual questioning of their clinical reasoning.

Collaborative and Transdisciplinary Reasoning Clinical decision making is rarely an isolated or independent process. Healthcare teams have been a traditional part of health care for some time, and the importance of teams is increasing. What we see today are evolutions in the idea and implementation of collaboration in practice, particularly around reasoning and decision making. This is evident in health practice models that emphasize mutual respect and collaboration, recognition of the knowledge of clients and caregivers as experts about the lives and health of clients, participation in collaborative decision making at a

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distance and using advanced technologies and, increasingly, transdisciplinary reasoning. Bridges are strengthening between orthodox and complementary medicine reasoning practices. The use of tools and protocols to facilitate client participation in decision making is constantly evolving.

Reasoning Across the Professions Section 4 takes an in-depth look at clinical reasoning in different health professions. What is striking are the similarities and the differences that reflect the overlapping but different goals of the professions. For example, emergency medicine specialists, paramedics and surgical teams need to make accurate diagnoses of presenting problems and sudden changes in acute settings as promptly as possible. Accuracy and speed of diagnosis in these situations can sometimes make the difference between life and death. In contrast, other health professions are often more concerned with managing long-term relationships with patients. Occupational therapists are usually dealing with patients for whom the diagnosis is well known. The issue for them is to work out how best to support patients over time and to co-create health enhancement or support narratives. Many disabled and elderly patients are not going to recover and can be expected to gradually deteriorate as time goes by. This means that the demands of clinical reasoning on health professionals who are managing patients with chronic conditions are quite different from those health professionals who are assessing acute conditions. Many health professions have to deal with both acute and chronic situations. Good examples are dentists and optometrists. They may spend the majority of their time working with long-term patients who will be regular visitors to the practice or clinic for years. However, health professionals must also be prepared to deal with acute emergency cases who might turn up at their practices at any time. Other trends in clinical reasoning are apparent in the different professions. One such trend is for health professions to become more autonomous. For example, we now have physician assistants and nurse practitioners. Physiotherapists too, in a growing number of countries, are now allowed to practice as independent practitioners without referrals from a physician. The similarities in

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clinical reasoning across different professions reflect this. At the same time, clinical practice is becoming more interprofessional with expectations that health professionals can adapt their clinical reasoning around the activities of other health professions. This is seen most strikingly in the work of nurses, hospital pharmacists and dietitians who often need to modify their clinical reasoning according to the needs of the team. The increasing complexity of health care and the rising standards of education and training in the health professions are all reflected in the increasing complexity of clinical reasoning and how the different professions understand what this entails.

Teaching Clinical Reasoning Our understanding of clinical reasoning and how we teach it continues to develop and is becoming more complex and sophisticated across all health professions. A critical challenge for educators is how we introduce newcomers to the health professions to this complexity and sophistication. Coping with the challenges of this task is the major topic of Section 5. As with the previous section there are similarities among health professions but also notable differences across the professions. The similarities reflect the commonalities that are shared in the teaching and learning processes as educators need to facilitate learning across classroom and workplace settings. The differences reflect the variations in the goals of the health professions and how they conceptualize their work with patients and clients. For example, speech pathologists have found classification systems, such as the International Classification of Functioning, Disability and Health (ICF), to be a particularly useful framework to organize clinical reasoning and how to teach it to students. This reflects the focus of speech pathology, which is the diagnosis and remediation of specific disabilities in speech. Nursing focuses on developing students' clinical reasoning abilities through teaching and learning strategies that foster lifelong critical thinking habits. Medicine typically advocates a curriculum for clinical reasoning for undergraduate medical education that is grounded in the science of reasoning practice with knowledge acquisition and clinical skill building, as well as introduction of concepts of clinical uncertainty

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and diagnostic error. A health profession may have a specific focus that distinguishes it from other professions, but we are now in a world where those health professions must collaborate as never before. Besides teaching clinical reasoning as the way ‘our’ profession does it, we now must teach our students how to modify their clinical reasoning when working in a team with other health professions and engage in shared decision making. The centrality of the situated and experiential nature of clinical reasoning is shared by all health professions. Our attempts to assess how well we teach clinical reasoning now have a long and complex history, reflecting the changes in how we define and theorize what clinical reasoning is.

Learning Clinical Reasoning This section of the book is aimed at teachers and learners who are working to facilitate, develop and better understand clinical reasoning. The focus of several chapters is on exploration of pedagogical and assessment strategies, grounded in educational theory, relevant to the teaching and learning of clinical reasoning in educational and practice-based learning contexts. Other chapters provide the reader with an understanding of research considerations and strategies for developing a better understanding of clinical reasoning and how to negotiate the integration of evidence into reasoning that leads to well-grounded clinical decisions. Key messages of this section include the importance of integrating explicit and theoretically sound strategies that bring to the surface and make visible the aspects of clinical reasoning that exist within multiple educational contexts, knowledge areas and practice activities. This includes an overt focus on the metaskills and capabilities necessary to communicate clinical reasoning and to learn from clinical reasoning experiences. Learners have to substantiate their decisions with appropriate evidence. Those who struggle need remediation. Readers are guided through a process of developing a conceptual framework for research about clinical reasoning and the scholarship of teaching and learning of clinical reasoning. This section contains significant updates from the previous

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edition, including new perspectives of ways in which today's educators can improve clinical reasoning learning and assessment outcomes by grounding their teaching and learning activities in sound educational strategies. As well as a significant update and expansion in content, the book design has added concrete examples, cases and vignettes to bring these discussions to life for the reader. Strategically placed reflection points assist readers to extend their insights and build learning from their own practical experiences and theoretical knowledge. As well as a key resource for practitioners, this book is a valuable resource for educators seeking to ground their teaching practices in educational theory, sound knowledge of clinical reasoning and practice-based evidence and researchers seeking to expand their research horizons. The book consolidates past knowledge and practices in the field of clinical reasoning, reflects current practices and provides insights and directions for future professional practice, learning, teaching and research of clinical reasoning. Joy Higgs, Gail M. Jensen, Stephen Loftus, Nicole Christensen

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List of Contributors Rola Ajjawi BAppSc(Physio)Hons, PhD, Senior Research Fellow, Centre for Research in Assessment and Digital Learning, Deakin University, Geelong, Victoria, Australia Jose F. Arocha MA, PhD, Associate Professor, School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada Nicole Blakey BN, Grad Dip Critical Care, MN, Senior Lecturer and National Professional Practice Lead (Nursing), Australian Catholic University, Brisbane, Queensland, Australia Henny P.A. Boshuizen PhD, Professor Emeritus Welten Institute, Open University of the Netherlands and Visiting Professor, Faculty of Education, Turku University, Finland Judith L. Bowen MD, Professor and Director, Education Scholars Program, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA Rosemary Brander PhD, MSc, Assistant Professor (Adjunct), School of Rehabilitation Therapy and Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada Christine Chapparo MA, PhD Senior Lecturer, Discipline of Occupational Therapy, Faculty of Health Sciences, University of Sydney, New South Wales; Associate Professor, Southern Cross University, Gold Coast,

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Queensland, Australia Nicole Christensen PhD, MAppSc, PT, Professor and Chair, Department of Physical Therapy, Samuel Merritt University, Oakland, California, USA Denise M. Connor MD, Associate Professor, Department of Medicine, University of California, San Francisco, California, USA Cindy Costanzo PhD, RN, CNL, Senior Associate Dean, Graduate School, Department Chair for Interdisciplinary Studies, Creighton University, Omaha, Nebraska, USA Jennifer L. Cox BSc, BMedSc(Hons), PhD, Lecturer, Biomedical Science, Charles Sturt University, Orange, New South Wales, Australia Pat Croskerry MD, PhD, Professor, Department of Emergency Medicine; Director, Critical Thinking Program, Dalhousie University Medical School, Halifax, Nova Scotia, Canada Rachel Davenport BSc(Hons), Clinical Education Coordinator, Speech Pathology, La Trobe University, Melbourne, Victoria, Australia Linda de Cossart CBE, ChM, FRCS, FAcadMed, Consultant Vascular and General Surgeon and Director of Medical Education, Countess of Chester Hospital; Honorary Professor, University of Chester, Chester, UK Clare Delany PhD MHlth & Med Law, M Physio(Manip), BAppScPhysio, Associate Professor, Department of Medical Education, University of Melbourne; Clinical Ethicist, Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia Gurpreet Dhaliwal MD, Professor of Medicine, University of California at San Francisco; Site Director, Internal Medicine Clerkships, San Francisco VA Medical Center, San Francisco, California, USA

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Janine Margarita Dizon BSPT, MSPT, PhD, Research Fellow, International Centre for Allied Health Evidence (iCAHE), University of South Australia, Adelaide, Australia Joy Doll OTD, OTR/L, Associate Professor, School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, USA Steven J. Durning MD, PhD, FACP, Professor and Director, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA Ian Edwards PhD, Grad Dip PT, Senior Lecturer, School of Health Sciences, University of South Australia, Adelaide, Australia Caroline Faucher OD, PhD, FAAO, Associate Professor, School of Optometry, Université de Montréal, Quebec, Canada Della Fish MA, MEd, PhD, PGCert, Visiting Professor, University of Chester, Education for Postgraduate Medical Practice, Chester, UK Maureen Hayes Fleming EdD, OTR, FAOTA, Associate Professor, Department of Occupational Therapy, Tufts UniversityBoston School of Occupational Therapy, Medford, Massachusetts, USA Sandra Grace PhD, MSc(Res), GradCertSportsChiro, DBM, DipAcup, DC, DO, DipEd, BA, Director of Research, School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales, Australia Susan Grieve DPT, MPT, MS, BS, Assistant Professor, Doctor of Physical Therapy, Samuel Merritt University, Oakland, California, USA Karen Grimmer PhD, MMedSc, LMusA, BPhty, Cert Health Ec, Professor Extraordinaire, Stellenbosch University, Cape Town, South Africa Jeannette Guerrasio MD,

Professor of Medicine and Director of

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Remediation, University of Colorado, Aurora, Colorado, USA Teresa Gwin EdD, FNP, MSN Family Nurse Practitioner, Samuel Merritt University, Oakland, California, USA Amy M. Haddad PhD, RN, Professor, Center for Health Policy and Ethics and the Dr. C.C. and Mabel L. Criss Endowed Chair in the Health Sciences, Creighton University, Omaha, Nebraska, USA Joy Higgs AM, PhD, MHPEd, BSc, PFHEA, Professor in Higher Education, Charles Sturt University, Sydney, Australia Debbie Horsfall PhD, MA, BEd, Professor of Sociology, Western Sydney University, Sydney, New South Wales, Australia Kathryn N. Huggett PhD, Robert Larner, MD Professor in Medical Education; Director, The Teaching Academy; Assistant Dean for Medical Education, The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA Gail M. Jensen PhD, PT, FAPTA, Dean, Graduate School and Vice Provost for Learning and Assessment; Professor, Department of Physical Therapy; Faculty Associate, Center for Health Policy and Ethics, Creighton University, Omaha, Nebraska, USA Robyn B. Johnson BAppSc(Speech Pathology), Associate Lecturer, Work Integrated Learning, Faculty of Health Sciences, University of Sydney, New South Wales, Australia Mark Jones CertPT, BS(Psych), Grad Dip Advan Manip Ther, MAppSc(Manip Physio), Senior Lecturer, Program Director, Master of Advanced Clinical Physiotherapy, School of Health Sciences, University of South Australia, Adelaide, Australia David R. Kaufman PhD Educational Psychology, MA Educational Psychology, BA Psychology, Associate Professor, Department of Biomedical Informatics, Arizona State University; Research Affiliate, Mayo Clinic, Scottsdale, Arizona, USA Belinda Kenny PhD, Lecturer, Work Integrated Learning, University of Sydney, New South Wales, Australia

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Shiva Khatami DDS, PhD, Diploma of the American Board of Orthodontics, Associate Professor, Department of Orthodontics and Dentofacial Orthopedics, Nova Southeastern University, Fort Lauderdale, Florida, USA Olga Kostopoulou PhD, Reader in Medical Decision Making, Department of Surgery & Cancer, Imperial College London, UK Juan N. Lessing MD, FACP, Assistant Professor, University of Colorado School of Medicine; Site Director, Hospitalized Adult Care Clerkship and Subinternship, University of Colorado Hospital, Denver, Colorado, USA Tracy Levett-Jones RN, PhD, MEd & Work, BN, DipAppSc(Nursing), Professor of Nursing Education, Discipline Lead – Nursing, University of Technology, Sydney, New South Wales, Australia Robin Moorman Li PharmD, BCACP, CPE, Clinical Associate Professor, University of Florida College of Pharmacy, Gainesville, Florida, USA Stephen Loftus PhD, MSc, BDS, Associate Professor of Medical Education, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA Bill Lord BHlthSc(Pre-HospCare), MEd, PhD, Associate Professor and Discipline Leader, Paramedicine, University of the Sunshine Coast, Sippy Downs, Queensland, Australia Kirsten McCaffery BSc(Hons), PhD, Professorial Research Fellow, School of Public Health, Sydney Medical School; NHMRC Career Development Fellow, Deputy Director, Public Health Section, Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), University of Sydney, New South Wales, Australia Michael MacEntee LDS(I), Dip Pros (MUSC), PhD, FCAHS, Professor Emeritus, Prosthodontics and Dental Geriatrics, University of British Columbia, Vancouver, Canada

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Anna Maio MD, General Internal Medicine, Department of Medicine, Creighton University, Omaha, Nebraska, USA Maria A. Martimianakis MA, MEd, PhD, Associate Professor and Director of Medical Education Scholarship, Department of Paediatrics; Scientist and Strategic Lead International, Wilson Centre, Faculty of Medicine, University of Toronto, Ontario, Canada Cheryl Mattingly PhD, Professor, Joint Appointment with the Department of Anthropology, University of Southern California, Dornsife College of Letters, Arts and Sciences, Los Angeles, California, USA W. Cary Mobley BSPharmacy, PhD, Clinical Associate Professor, University of Florida College of Pharmacy, Gainesville, Florida, USA Maria Mylopoulos PhD, Associate Professor, Department of Paediatrics; Scientist, The Wilson Centre, University of Toronto, Ontario, Canada Geoffrey R. Norman PhD, Professor Emeritus, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada Vimla L. Patel PhD Senior Research Scientist and Director, Centre for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York; Professor of Biomedical Informatics, Arizona State University, Phoenix, Arizona, USA Narelle Patton PhD, Sub Dean Workplace Learning and Accreditation (Faculty of Science), Charles Sturt University, Sydney, New South Wales, Australia Jacqueline Pich PhD, BNurs, BSc, Lecturer, University of Technology, Sydney, New South Wales, Australia Judy Ranka BSc(OT), MA, HlthScD

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Director and Principal Occupational Therapist, Occupational Performance Network; Honorary Academic Affiliate, Discipline of Occupational Therapy, University of Sydney, New South Wales; Adjunct Research Associate, Charles Sturt University, Albury, New South Wales, Australia Linda J. Resnik PhD, PT, Research Career Scientist, Providence VA Medical Center; Professor, Health Services Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA Barbara J. Ritter EdD, FNP, Lecturer, Sonoma State University, Rohnert Park, California, USA Henk G. Schmidt PhD, Professor of Psychology, Institute of Psychology, Erasmus University, Rotterdam, The Netherlands Lambert W.T. Schuwirth MD, PhD Professor of Medical Education, Director Prideaux Centre for Research in Health Professions Education, College of Medicine and Public Health, Flinders University, Adelaide, Australia; Professor for Innovative Assessment, Department of Educational Development and Research, Maastricht University, Maastricht, The Netherlands; Distinguished Professor of Medical Education, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan; Professor of Medicine (Adjunct), Uniformed Services University for the Health Sciences, Bethesda, Maryland, USA Alan Schwartz PhD, The Michael Reese Endowed Professor of Medical Education and Associate Head, Department of Medical Education; Research Professor, Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, USA Maree Donna Simpson BPharm, BSc (Hons), PhD, GradCert Univ Teach & Learn, Discipline Leader Pharmacy and Health Studies, Charles Sturt University, Orange, New South Wales, Australia

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Paul Simpson PhD, MScM, GradCert Paediatric Emergencies, GradCert Clinical Education, BHSc, BEd(PD/H/PE), AdvDip Paramedical Science, Senior Lecturer and Director of Academic Program (Paramedicine), Western Sydney University, New South Wales, Australia Megan Smith PhD, MAppSc(Cardiopulm physio), BAppSc(Physio), Professor and Deputy Dean, Faculty of Science, Director, Three Rivers University Department of Rural Health, Charles Sturt University, Sydney, New South Wales, Australia Catherine Suttle PhD, Senior Lecturer in Optometry and Visual Science, City, University of London, UK Diane Tasker PhD, Partner, The Education, Practice and Employability Network, Sydney, Australia Jill E. Thistlethwaite MBBS, PhD, MMEd, FRCGP, FRACGP Health Professions Education Consultant, Medical Adviser NPS MedicineWise, Sydney; Adjunct Professor, University of Technology, Sydney; Honorary Professor University of Queensland, Brisbane, Australia Aliki Thomas BSc, OT, MEd, PhD, Assistant Professor, School of Physical and Occupational Therapy; Research Scientist, Center for Medical Education, McGill University Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Quebec, Canada Franziska Trede PhD, MHPEd, Dip Physiotherapy, Associate Professor, Institute for Interactive Media and Learning, University of Technology, Sydney, New South Wales, Australia Lyndal Trevena PhD, Professor, Primary Health Care, Sydney School of Public Health, University of Sydney, New South Wales, Australia Merrill Turpin BOccThy, Grad Dip Counsel, PhD, Senior Lecturer, School of Health and Rehabilitation, University of Queensland, Brisbane, Australia Cees P.M. van der Vleuten PhD,

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Scientific Director, School of

Health Professions Education, Maastricht University, Maastricht, The Netherlands Celeste Villanueva EdD, CRNA, FNAP, Assistant Academic Vice President, Director, Health Sciences Simulation Center, Samuel Merritt University, Oakland, California, USA Ruth Vo BNutrDiet(Hons), MHSc(Edu), Accredited Practising Dietitian (APD); PhD Candidate, Charles Sturt University, Sydney, New South Wales, Australia Jason A. Wasserman PhD, Associate Professor of Biomedical Sciences (Primary), Associate Professor of Pediatrics (Secondary), Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA Michael J. Witte MD, Chief Medical Officer, California Primary Care Association, Sacramento, California, USA Nicole A. Yoskowitz PhD, Postdoctoral Fellow at Behavioral Associates, New York, New York, USA Meredith Young PhD, Assistant Professor, Department of Medicine; Research Scientist, Centre for Medical Education; McGill University, Montreal, Quebec, Canada Mohammad S.Y. Zubairi MD, MEd, FRCPC, Developmental Paediatrician, Holland Bloorview Kids Rehabilitation Hospital; Clinical Team Investigator, Bloorview Research Institute; Assistant Professor, Department of Paediatrics, University of Toronto, Ontario, Canada

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Acknowledgements The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions' contributors. Their input provided an important foundation for the ideas that have been extended in this volume. Our thanks to Ros Allum, Jennifer Pace-Feraud, and Kim Woodland for their valuable assistance in preparation of this manuscript.

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SECTION 1

Understanding Clinical Reasoning OUTLINE 1 Clinical Reasoning Challenges of Interpretation and Practice in the 21st Century 2 Re-Interpreting Clinical Reasoning A Model of Encultured Decision-Making Practice Capabilities 3 Multiple Spaces of Choice, Engagement and Influence in Clinical Decision Making 4 Clinical Reasoning and Models of Practice 5 The Development of Clinical Reasoning Expertise 6 Expertise and Clinical Reasoning

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1

Clinical Reasoning Challenges of Interpretation and Practice in the 21st Century Joy Higgs, Gail M. Jensen

CHAPTER AIMS The aim of this chapter is to introduce key themes explored in this book in relation to: ▪ current understandings in the term and practice of clinical reasoning, ▪ challenges faced by people engaged in decision making and ▪ challenges faced by people engaged in learning and teaching clinical reasoning.

KEY WORDS Clinical reasoning Clinical decision making

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Understanding Clinical Reasoning Clinical reasoning is the core of clinical practice; it enables practitioners to make informed and responsible clinical decisions and address problems faced by their patients or clients. It involves wise action, meaning taking the best judged action in a specific context (Higgs, 2016); professional action encompassing ethical, accountable and self-regulatory decisions and conduct; and personcentred action that demonstrates respect for and collaboration with clients, carers and colleagues. It has been over 20 years since the first edition of this book was produced (Higgs and Jones, 1995). While there have been changes to our editors and authors list and considerable changes to the book content, the key idea of clinical reasoning being both a simple and complex phenomenon has remained (Higgs, 2006). Simply, clinical reasoning is the thinking and decision-making processes associated with clinical practice; it is a critical capability in the health professions, central to the practice of professional autonomy that permeates clinical practice. At a complex level, clinical reasoning is a multilayered and multicomponent capability that allows practitioners to make difficult decisions in the conditions of complexity and uncertainty that often occur in health care. Such decisions require a high level of tolerance of ambiguity, reflexive understanding, practice artistry and collaboration. There is no one model of clinical reasoning that best, or comprehensively, represents what clinical reasoning is in the contexts of different professions and different workplaces. The reason for this lies in several factors:

▪ The complex nature of the phenomenon of clinical reasoning and the consequential challenges of understanding, researching, assessing and measuring it. ▪ The context-dependent nature of clinical decision making in action. ▪ The inherent individuality of expertise. ▪ The changing conceptions of quality and error in 49

clinical reasoning. ▪ The challenge to novices in developing clinical reasoning skills and to educators in facilitating this development. ▪ The changing volume and nature of the demands of factors influencing health care, its costs, its consequences and its modes of operation. Ratcliffe and Durning (2015, p. 13) provide this overview of clinical reasoning: ‘although definitions and descriptions of clinical reasoning entail the cognitive operations allowing clinicians to observe, collect and analyze information, resulting in actions that take into account a patient's specific circumstances and preferences’. They add that ‘many scholars now view clinical reasoning as having both cognitive and noncognitive domains as well as being a social as opposed to an individual construct’ (p. 14). These considerations are reflected in the following two definitions. We define clinical reasoning as the cognitive and noncognitive process by which a healthcare professional consciously and unconsciously interacts with the patient and environment to collect and interpret patient data, weigh the benefits and risks of actions, and understand patient preferences to determine a working diagnostic and therapeutic management plan whose purpose is to improve a patient's well-being (Trowbridge et al., 2015, p. xvii). Clinical reasoning (or practice decision making) is a contextdependent way of thinking and decision making in professional practice to guide practice actions. It involves the construction of narratives to make sense of the multiple factors and interests pertaining to the current reasoning task. It occurs within a set of problem spaces informed by the practitioner's unique frames of reference, workplace context and practice models, as well as by the patient's or client's contexts. It utilizes core dimensions of practice knowledge, reasoning and metacognition and draws on these

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capacities in others. Decision making within clinical reasoning occurs at micro, macro and meta levels and may be individually or collaboratively conducted. It involves meta skills of critical conversations, knowledge generation, practice model authenticity and reflexivity (Higgs, 2006). The authors in this book and others across the literature often use clinical reasoning and decision making synonymously. We recognize that this interchange is common, and, alternatively, some professions and writers use the terms distinctly. Here we make the distinction that clinical reasoning is the overall process of thinking during clinical practice, while clinical decision making could be seen to emphasize the outputs or decisions.

Reflection Point 1 What is your definition of clinical reasoning? What experiences can you describe of clinical reasoning as a cognitive and noncognitive process?

Challenges Faced by People Engaged in Clinical Decision Making In this section, we will explore four key challenges faced by people engaged in clinical decision making:

▪ Dealing with a complex world ▪ Dealing with wicked problems in a world that looks for accountability and evidence clarity ▪ Addressing complex real-world problems, human tasks with consequences for life and quality of life ▪ Dealing with issues associated with sharing decision-making processes and outcomes

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Challenges of Dealing With a Complex World Bauman's (2000, 2005) ‘liquid modernity’ metaphor captures the values and desires that characterize the prosperous West today. Casting aside the attitudes that predominated in the second half of the 20th century (such as the vision that puts others first, the sense of mystery of things beyond us and recognition of the fallibility of human knowledge), liquid modernity challenges the ideals of service and moral responsibility of professions in meeting societal needs. Bauman's ideas highlight current trends, such as taking shortcuts to increase perceived efficiencies, outsourcing work and resources provision and being preoccupied with short-term goals and desires instead of long-term pursuits. This is seen in changing consumerist ideas such as replacing long-lasting products with shorter, fixed-term products and changing lifetime employment with casual jobs. The liquid-modern age pursues instant gratification and constant movement (which goes beyond fluency and flexibility to volatility, fragmentation and short life spans of knowledge, tasks, work groups and so on). This contrasts with the ongoing commitments of healthcare professionals to patients, to best possible care, to persistence, to resilience, to carefulness and to obligations arising from and through multiprofessional teamwork. Another problem is the changing attitude towards knowledge in the liquid-modern world, where established knowledge and know-how have an increasingly shorter shelf life. Tradition and experience seem to be no longer valued. A key issue in clinical reasoning is the demand for practitioners to be able to explain professional matters articulately and clearly to all parties and to take proper account of their own values as well as the needs and values of all those involved or influential in patient/client care. Fish and Higgs (2008) contend that responsible members of a profession need to argue their moral position; implement their roles with proper transparency and integrity; and their clinical thinking, utilize professional judgement and practice wisdom to serve the needs of differing individuals as well as understand and work towards the common good.

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A second key element of the complexity of the worlds of practice and health care today is the digital revolution, which poses both opportunities and challenges to health care, clinical reasoning and the making and communication of clinical decisions. Sennett (2005), reviewing culture and society for several decades in Britain and America, reflects on the challenges facing us all today because of the unstable, fragmentary conditions in society and work. He contends that not everyone will thrive in the face of ‘hot-desking’ workplaces and in ‘dot.com’ modelled hospital and university workplaces. O'Neill (2002) critiques today's systems of accountability that are driven by the human resources industry and are designed to provide transparent checks on the implementation of change. The critique is that constant checking on people's work progress and outcomes in support of transparency actually damages trust and does not allow change to consolidate. Of particular interest, in relation to clinical reasoning, are the strategies and tools that have been developed with the goal of assisting decision making and communication. Studies in this area include the work of Chaudhry et al. (2006), who demonstrated improved quality and efficiency of health information technologies across four benchmark institutions. Buntin et al. (2011) provide support for the adoption of electronic health records and information technology. They found that such tools and strategies had largely positive benefits, but the ‘human element’ was critical to health information technology implementation. Chau and Hu (2002) examined different theories and strategies for implementing telemedicine; they reported variation in the acceptability of different telemedicine approaches, linked to differences in the essential characteristics of user, technology and context. Osheroff et al. (2007, p. 141) examined the value of clinical decision support that provides practitioners, patients and others with ‘knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. It encompasses a variety of tools and interventions such as computerized alerts and reminders, clinical guidelines, order sets, patient data reports and dashboards, documentation templates, diagnostic support, and clinical workflow tools’. They concluded that some healthcare institutions achieved positive benefits for knowledge users while others faced problems. The

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demand for reliable health information to support decisions is being driven by consumerism and moves to shift the cost of care to patients and increase client input to decision making. Koch (2006) raises the concern of the potential negative effect of home telehealth on the patient–provider relationship, particularly in relation to special user groups, such as people who are elderly or have a disability. She calls for further exploration of the use of such strategies.

Reflection Point 2 How do you think we should go about linking the headspace of personal reasoning with the etherspace of technology-enabled reasoning? What experience have you had in this area? How would you advise novices about this area?

Challenges in Addressing Wicked Problems and Accountability Clinical reasoning and decision making are essentially professional problem solving – solving the problem or challenge of making decisions about diagnosis, prognosis, treatment options and preferences and so on as a way of informing healthcare actions by practitioners and clients. Schön (1987) reminds us that the process of problem setting, the ability to identify the problem in the swampy lowland of practice, requires seeing the situation or context from multiple frames of reference. Roberts (2000) identifies three types of problems (Table 1.1) with different levels of complexity and solution/management solution. TABLE 1.1 Types of Problems Type 1 problems Type 2 problems

are ‘simple problems’ that enjoy a consensus on a problem definition and solution. are ‘complex problems’ that introduce conflict to the problem-solving process. While problem solvers agree on what the problem is, there is no consensus on how to solve it.

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Type 3 are ‘wicked problems’ that engender a high level of conflict among the problems stakeholders. The problem-solving process is not bound – it is experienced as ambiguous, fluid, complex, political and frustrating.

Based on Roberts, N., 2000. Wicked problems and network approaches to resolution. IPMR 1, 1–19.

Wicked problems (Roberts, 2000) have the following characteristics: 1. There is no definitive statement of the problem; indeed, there is typically broad disagreement on what ‘the problem’ is. 2. Without a definitive statement of the problem, the search for solutions is open ended. People who have a stake in the problem and its solution, the stakeholders, play various competing and changing roles from their perspectives including framing the problem, supporting and shaping different solutions. 3. The problem-solving process is complex because constraints, such as resources and political ramifications, are constantly changing. 4. Constraints also change because they are generated by numerous interested parties who may bring variable levels of participation to the problem solving and whose input can vary as they change their minds, fail to communicate well and change their frame of reference in addressing the problem. The very idea of wicked problems runs contrary to the search for ‘correct’ answers and the unequivocal justification of clinical decisions. Consider diagnostic and treatment decisions, for instance. While in some cases a clear diagnosis is straightforward and necessary, particularly in life-threatening situations, it is often the case that comorbidities exist. The clinical condition might be rare, unfamiliar or hard to diagnose. Treatment decisions are multifactorial, facing variables like skill levels of practitioners, available funding, resourcing and client wishes. For instance, a client/patient may aspire to a health and well-being narrative that runs contrary to the ‘restitution narrative’ (i.e., return to normality).

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The latter is particularly the case for people with chronic health problems (Alder and Horsfall, 2008). Further, decision paradigms and cultures vary across different professions. Again, we see clinical reasoning and decision making as complex phenomena.

Reflection Point 3 Where does evidence in support of our decisions fit with these decisions and actions? Consider the arguments put forward in Chapters 4 and 5 (expertise), Section 3 chapters (collaborative and transdisciplinary decision making) and Section 4 chapters (clinical reasoning across the professions).

Challenges of Making Complex and Consequential Decisions Orasanu and Connolly (1993) examined the real world of clinical decision making and described the characteristics of decision making in dynamic settings as follows:

▪ Problems are ill-structured and made ambiguous by the presence of incomplete dynamic information and multiple interacting goals. ▪ The decision-making environment is uncertain and may change while decisions are being made. ▪ Goals may be shifting, ill-defined or competing. ▪ Decision making occurs in the form of action– feedback loops, where actions result in effects and generate further information that decision makers have to react to, and use, to make further decisions. ▪ Decisions contain elements of time pressure, personal stress and highly significant outcomes for the participants. 56

▪ Multiple players act together, with different roles. ▪ Organizational goals and norms influence decision making. To work within such a practice world requires an approach to clinical reasoning that accommodates these complexities. Higgs et al. (2006) described a number of key characteristics of clinical reasoning needed to address these challenges:

▪ Clinical reasoning as a solo process is a complex, mostly invisible, process that is often largely automatic and therefore not readily accessible to others in practice or research. ▪ Clinical reasoning is linked with more visible behaviours such as recording diagnoses and treatment plans in patient histories and communicating treatment rationales in team meetings, case conferences and teaching novices. ▪ Clinical reasoning and practice knowledge are mutually developmental; each relies on the other, each gives meaning to the other in the achievement of practice and each is the source of generation and development of the other. ▪ Clinical reasoning can be implemented as a sole practitioner process or a group process. ▪ Clinical reasoning may be understood as both cognitive and collaborative processes; however, in either case there is a growing imperative, linked to increasing demands for evidence-based practice and public accountability, to make reasoning more explicit. 57

▪ The idea of evidence means different things in different contexts and paradigms (see Turpin and Higgs, 2017); understanding evidence is important when planning to use or require evidence-based practice. ▪ Core reasoning abilities, language and interactive behaviours are required for understanding and developing practice knowledge and clinical reasoning. ▪ It is important to understand clinical reasoning behaviours and effectiveness (including the communication of reasoning) in relation to contextual influences, including the practice model that has been chosen or imposed. ▪ Clinical reasoning requires a range of capabilities including cognitive, metacognitive, emotional, reflexive and social capabilities. ▪ Clinical reasoning is, and for the purposes of quality assurance, should be, a reflexive process that involves practitioner(s) in critical selfreflection and ongoing development of their reasoning abilities, knowledge and communication (of reasoning) abilities. So, what has the 21st century brought to this practice space that further challenges clinical reasoning practice? Some of the most critical factors, we believe, include:

▪ The technological and digital revolutions, which have increased the use of high-level technology in health care (for those who can afford it) and hightech communication and decision-making aids in 58

the practice of clinical decision making and its communication. Examples of these trends include robotics, telehealth, use of big data and selfdoctoring. ▪ The further erosion of professionalism often linked to a decline in altruism and an increase in self-interest and expectations privilege by practitioners. ▪ An escalation in the demand by patients/clients and carers for respectful and informed participation in clinical decision making. This has been greatly effected by readily accessible information on the Internet. ▪ Globalization (the global spread of capitalism as an economic system) and neoliberalism (the support of a deregulated global market society) have brought increasing emphasis in health care (and therefore clinical decision making) on commodification of health care, fiscal accountability often in advance of ethical accountability, replacement of service-oriented professionals with business-oriented entrepreneurs, corporatization of professional practices, increasing litigation by consumers and more widespread adoption of systems and practices that shift the economic cost/burden of health care to the individual rather than the state. Professionals are under increasingly more pressure on a number of fronts from higher demands for standards of professional competence and fiscal demands for increased productivity, to external regulations that require sound evidence, efficiency and

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accountability. These challenges also affect professional autonomy and control. Sullivan and Benner (2005, p. 79) describe this well: ‘the question of how healthcare professionals can function as prudent managers in the public interest, as well as engaged autonomous professionals, takes on salience in this new environment’. Now more than ever, healthcare professionals need not only strong cognitive and analytical skills but integrity, individual self-awareness and the ability to engage in clinical reasoning that leads to wise judgement. Consider how you would respond to the situation presented in the following case study.

Case Study 1.1

Misalignment of Professional Autonomy, Accountability and Evidence Dan, a newly licensed physical therapist, was working at a clinic where the organization had a clinical standard–to achieve at least 52 minutes and 4 billable units with each patient. He was told that this was the expectation for maintaining productivity and that as a skilled clinician he should be able to work with any patient for 52 minutes. If he couldn't, then he should not consider himself a skilled clinician. It did not take long for him to experience moral distress as he was trying to balance his ability to make clinical decisions about patient discharge and accountability for being a good steward of healthcare resources in balance with evidencebased practice guidelines and now organizational expectations. His patient, Joan, had adhesive capsulitis of her shoulder and had reached all of her goals. Joan was well aware of everything she needed to do after therapy, was experiencing no pain, had achieved functional goals and was ready for discharge. Dan ended up keeping the patient for only 30 minutes and was confronted by the clinic manager for not maintaining productivity for that hour with that patient. Dan was following best practice clinical guidelines and believed that as a practising physical therapist, he had professional responsibility for patient-centred quality care along with being a steward of scarce healthcare resources.

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Challenges in Sharing DecisionMaking Processes and Outcomes Interprofessional collaboration is being promoted by healthcare organizations, governments and regulatory groups as an important means to addressing many of the complex and wicked problems in caring for patients, improving health organization performance measures, managing escalating costs and improving health outcomes (Frenk et al., 2010; Royeen et al., 2009). (Refer to the chapters in Section 3 of this book for further work on collaborative decision making.) Professional education accreditation requirements are moving rapidly in response to this need for interprofessional collaboration and setting standards for institutions to demonstrate that graduates are ‘collaboration ready’ (Prystajecky et al., 2017). The successful care of patients and communities depends not only on the knowledge and expertise of the individual practitioner but the collective knowledge and distributed intelligence of the interprofessional team (Cooke et al., 2010; Jensen, 2011). This distributed intelligence of the team often requires a process of shared decision making as patients and the interprofessional team members work together in the decision-making process. The development of the specific health profession's clinical reasoning abilities is a central focus in professional education and often leaves little time for an intentional focus on shared decision making. Therefore it is essential that the development of clinical reasoning from novice to expert has an intentional focus on key concepts. These key concepts include the critical relationship between knowledge restructuring and clinical reasoning and level of expertise, the importance of adaptive expertise and the concept of progressive problem solving, outlined in Chapters 5 and 6 on clinical reasoning expertise.

Reflection Point 4 What are teaching and learning strategies that could be used to engage learners in shared decision-making processes? How would you apply key ideas for the ongoing development of

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expertise in clinical reasoning and the concept of adaptive expertise in your clinical teaching?

Challenges Faced by People Engaged in Learning and Teaching Clinical Reasoning In this section we will explore three key challenges faced by people engaged in clinical reasoning and decision making:

▪ intentionally building clinical reasoning teaching and learning into pressured curricula, ▪ teaching and learning the often more tacit elements in clinical reasoning along with the ambiguous, complex realities and ‘wickedness’ of clinical reasoning and ▪ learning about how professionals often have to make judgements in uncertain conditions

Building Clinical Reasoning Into Curricula Health sciences curricula tend to follow a number of patterns: discipline-content driven preclinical and clinical courses, problembased courses and practice-based curricula. These vary in the attention given to clinical problem solving, clinical reasoning and clinical decision making as part of the curricula. A key goal of this book is to emphasize the importance of overtly and experientially teaching clinical reasoning as part of any curriculum. Section 5 of the book provides multiple examples of curriculum, learning and teaching approaches adopted across the professions including:

▪ application of a clinical thinking pathway for surgeons that uses a formulaic approach along 62

with humane and individualistic approaches, ▪ creative strategies such as deconstructing critical events and reflecting on cognitive biases as part of teaching clinical reasoning in nursing and ▪ understanding the centrality of context in the teaching and learning of clinical reasoning in academic and workplace environments as essential.

Teaching and Learning Clinical Reasoning Complexities We have argued that clinical reasoning – once you approach it deeply and in many complex circumstances – is a challenging thing to do. Fig. 1.1 illustrates the definition of clinical reasoning by Higgs (2006). We see in this figure different types of decisions, multiple decision spaces (see Higgs and Jones, 2008), the foundational dimensions of clinical reasoning, the players in the clinical decision-making process and meta processes framing the practices of clinical reasoning and decision making. This, or any other interpretation of clinical reasoning as a complex process, highlights the challenges that even experienced practitioners, let alone novices, face when engaging in this critical component of clinical practice.

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FIG. 1.1 Clinical reasoning: A challenging practice. (From Higgs, J., Trede, F., Loftus, S., et al., 2006. Advancing clinical reasoning: Interpretive research perspectives grounded in professional practice. CPEA, Occasional Paper 4, Collaborations in Practice and Education Advancement. University of Sydney, Australia, with permission.)

Learning Something That's Not Simply Black and White Section 6 deals with learning clinical reasoning, both from the perspective of providing learning opportunities and activities for learners, ranging from direct clinical experience, to online learning activities and self-directed learning. In each case, learners need to come to an understanding of what their job requires of them in relation to making clinical decisions, what is expected of them and what the consequences of their reasoning are for their clients, colleagues and themselves and also what strategies they can adopt as part of their lifelong learning commitment to continue to develop their reasoning abilities. Students and novice professionals often experience insecurities when they become responsible for people's lives and well-being in clinical situations. It takes time to build up the capacity to reason well in situations that are complex and to

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become confident in performing this core practice. Chapters 5 and 6 pursue this journey of developing confidence, capability and expertise in clinical reasoning.

Reflection Point 5 As a novice or experienced practitioner reflect on these questions: • What do I know about clinical reasoning? What does it mean in my practice? • How well do I reason – not just in terms of avoiding errors and making sound decisions – but also in terms of working across different communities of practice (e.g., within my profession, across work teams, with my clients as active decision-making participants)? • How can I improve my clinical decision making? What strategies work well for me? Who can I ask for help to further develop my clinical reasoning capability?

Chapter Summary In this chapter we have explored a number of arguments:

▪ There is no universal model of clinical reasoning that fits all settings, professions and individuals, but we recognize this as a complex phenomenon that includes cognitive and noncognitive processes. ▪ Dealing with a complex world presents healthcare professionals with ‘wicked problems’ that require approaches to clinical reasoning that can accommodate and address these complexities. ▪ Increasing demands for interprofessional collaboration and client engagement bring the need for greater understanding of shared decision 65

making. ▪ The challenges in teaching and learning clinical reasoning provide great opportunities for innovation, exploration and assessment of learning. Reflection Point 6 Fig. 1.1 Clinical reasoning: A challenging practice – provides an overview of many of the key concepts in this chapter that are also further detailed in the book. What component(s) is most challenging for your learners? What will you focus on in your teaching clinical reasoning?

References Alder S, Horsfall D. Beyond the restitution narrative: lived bodies and expert patients. Higgs J, Jones MA, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:349– 356. Bauman Z. Liquid Modernity. Polity Press: Cambridge; 2000. Bauman Z. The liquid modern challenges to education. Robinson S, Katulushi C. Values in Higher Education, Aureus and the University of Leeds. Leeds: UK; 2005:36–50. Buntin MB, Burke MF, Hoaglin MC, et al. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff. (Millwood). 2011;30:464– 471. Chau PYK, Hu PJ. Investigating healthcare professionals' decisions to accept telemedicine

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technology: an empirical test of competing theories. Inf. Manag.2002;39:297–311. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann. Intern. Med.2006;144:742–752. Cooke M, Irby D, O'Brien B. Educating Physicians: A Call for Reform of Medical School and Residency. Jossey-Bass: San Francisco, CA; 2010. Fish D, Higgs J. The context for clinical decision making in the 21st century. Higgs J, Jones MA, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:19– 30. Frenk J, Bhutta Z, Cohen J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–1958. Higgs J. The complexity of clinical reasoning: exploring the dimensions of clinical reasoning expertise as a situated, lived phenomenon. [Seminar presentation at the Faculty of Health Sciences, University of Sydney, Australia, 5 May] 2006. Higgs J. Practice wisdom and wise practice: dancing between the core and the margins of practice discourse and lived practice. Higgs J, Trede F. Professional Practice Discourse Marginalia. Sense: Rotterdam, The Netherlands; 2016:65–72. Higgs J, Jones MA. Clinical Reasoning in the Health Professions. Butterworth-Heinemann: Oxford; 1995. Higgs J, Jones MA. Clinical decision making and multiple problem spaces. Higgs J, Jones MA, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:3– 17.

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Higgs J, Trede F, Loftus S, et al. Advancing clinical reasoning: interpretive research perspectives grounded in professional practice, CPEA, Occasional Paper 4. [Collaborations in Practice and Education Advancement, University of Sydney, Australia] 2006. Jensen GM. The Forty-Second Mary McMillan Lecture: Learning: what matters most. Phys. Ther.2011;91:1674–1689. Koch S. Home telehealth: current state and future trends. Int. J. Med. Inform.2006;75:565–576. O'Neill O. A Question of Trust. Polity Press: Cambridge; 2002. Orasanu J, Connolly T. The reinvention of decision making. Klein GA, Orasanu J, Calderwood R, et al. Decision Making in Action: Models and Methods. Ablex: Norwood, NJ; 1993:3–20. Osheroff JA, Teich JM, Middleton B, et al. A roadmap for national action on clinical decision support. J. Am. Med. Inform. Assoc.2007;14:141–145. Prystajecky M, Lee T, Abonyi S, et al. A case study of healthcare providers' goals during interprofessional rounds. J. Interprof. Care. 2017;31:463–469. Ratcliffe TA, Durning SJ. Theoretical concepts to consider in providing clinical reasoning instruction. Trowbridge RL, Rencic JJ, Durning SJ. Teaching Clinical Reasoning. American College of Physicians: Philadelphia, PA; 2015:13–30. Roberts N. Wicked problems and network approaches to resolution. IPMR. 2000;1:1–19. Royeen C, Jensen GM, Harvan R. Leadership in Interprofessional Health Education and Practice. Jones & Bartlett Learning: Boston, MA; 2009. Schön D. Educating the Reflective Practitioner. Jossey-

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Bass: San Francisco, CA; 1987. Sennett R. The Culture of the New Capitalism. Yale University Press: New Haven, CT; 2005. Sullivan W, Benner P. Challenges to professionalism: work integrity and the call to renew and strengthen the social contract of the professions. Am. J. Crit. Care. 2005;14:78–84. Trowbridge RL, Rencic JJ, Durning SJ. Introduction/Preface. Trowbridge RL, Rencic JJ, Durning SJ. Teaching Clinical Reasoning. American College of Physicians: Philadelphia, PA; 2015:xvii– xxii. Turpin M, Higgs J. Clinical reasoning and evidencebased practice. Hoffmann T, Bennett S, Del Mar C. Evidence-Based Practice: Across the Health Professions. Elsevier: Chatswood; 2017:364–383.

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2

Re-Interpreting Clinical Reasoning A Model of Encultured DecisionMaking Practice Capabilities Joy Higgs

CHAPTER AIMS The aims of this chapter are to: ▪ re-interpret clinical reasoning as a complex practice through the lens of enculturation, ▪ recognize the place of social, practice and epistemic cultures in framing clinical reasoning and decision making, ▪ explore the connection between clinical reasoning, learning and knowing in practice, ▪ recognize the place of epistemic-ontological fluency as an approach to developing and practising clinical reasoning capability in professional practice and ▪ present a model of clinical reasoning as encultured decision-making practice capabilities.

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KEY WORDS Encultured Epistemological practice Fluency Ontological practice The complexity of clinical reasoning is inherent in the very nature of the task or challenge, faced by novice and expert alike. This challenge is to process multiple variables, contemplate the various priorities of competing healthcare needs, negotiate the interests of different participants in the decision-making process, inform all decisions and actions with advanced practice knowledge and make decisions and take actions in the accountable context of professional ethics and community expectations. By encompassing much of what it means to be a professional (autonomy, responsibility, accountability and decision making in complex situations), clinical reasoning is imbued with an inherent mystique. This mystique is most evident in the way expert practitioners make difficult decisions with seemingly effortless simplicity and justification and in the professional artistry and practice wisdom of experienced practitioners who produce, with humanity and finesse, individually tailored health management plans that address complicated health needs. To address and achieve these professional attributes, clinical reasoning is much more a lived phenomenon, an experience, a way of being and a chosen model of practising than it is simply a process. It is enacted through a set of capabilities that demonstrate current knowledge and practice expertise and the capacity to work in unknown and unpredictable situations.

Re-Interpreting Clinical Reasoning Many chapters in this book hint at or openly declare the need for reinterpretation of clinical reasoning for multiple reasons including:

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▪ the escalation of research and scholarship on clinical reasoning, which is exploring the complexities and demands of clinical reasoning in a range of human, professional and institutional healthcare spaces; ▪ the far greater current emphasis on shared decision making (among multidisciplinary teams and with clients and carers); ▪ the quantum shift in the use of technology and digital communication systems to aid the reasoning, communication and collaboration involved in clinical decision making; ▪ the changing local and global contexts of health care and decision making, including influences and challenges posed by and to evidence-based practice, changing expectations and capacities of healthcare consumers and healthcare economic factors (including escalating healthcare costs, the difficulty – even impossibility – of public funding of health care for all citizens and the large proportion of populations who cannot self-fund their health care); ▪ the need to see clinical reasoning as knowledge use and development in practice, not the application of prior knowledge to clinical decision making and ▪ the need to view clinical reasoning and decision making as collaborative, holistic practices actioned by practitioners and clients, assisted by technology as appropriate.

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The re-interpretation presented in this chapter builds on the following key arguments:

▪ Encultured Practice: Clinical reasoning is a way of thinking and decision making that is developed within the framework of various cultural arenas: the world of healthcare practice and the societal and organizational cultures that shape healthcare practices and systems, the multiple worlds and cultures of healthcare clients and professional practice cultures. ▪ Understanding Professional Practice Paradigms: Clinical reasoning and decision making operate within communities of practice. To operate within these practice communities and their cultures requires a deep understanding of the practice paradigms underpinning them. ▪ Knowing, Being and Identity in Practice: Deliberate choices and ownership by practitioners of their practice models and their approaches to reasoning and collaboration are essential for advanced practice. Informed and owned practice comprises doing, knowing, being and becoming and chosen stances on practice epistemology and practice ontology. ▪ Practice-in-Action: Practice actions, knowledge, reasoning and discourse operate symbiotically; they are essential organic aspects of practice-inaction. ▪ Pursuing Clinical Reasoning Capability: Viewed as a capability clinical reasoning is a journey of development in self-realization, interaction and 73

critical appraisal. The chapter will extend this discussion and produce a revised definition of clinical reasoning and a model of modes of encultured and contextualized reasoning.

Reflection Point 1 What is your understanding of clinical reasoning and decision making? Do you draw the ideas discussed earlier into your practice?

Clinical Reasoning as an Encultured Practice Clinical reasoning operates within practice settings and multiple cultures including socio-political and instructional cultures, client health and well-being contexts and cultures, professional practice cultures and communities of practice. These cultures are created and entered through rich social construction and interaction processes, in particular, professionalization of occupations and the professional socialization of individuals entering the profession.

Culture Culture is the characteristics, social behaviour and customs of a particular group of people (a society, community, ethnic group). It encompasses the beliefs, language, customs and the acquired knowledge of societies, so named as a result of their ongoing interaction and patterns of expected social behaviour and organization. Culture is expressed through material forms (technologies, artefacts, tool usage, art and architecture) and nonmaterial forms (politics, mythology and science). Culture is created and transmitted through social learning in human social groups both as a means of individual enculturation and as a way of maintaining that culture through succeeding generations. Culture can also refer to the set of shared attitudes, values, conventions,

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goals and social practices that characterize a particular field, discipline, institution or organization.

Socio-Political and Institutional Cultures Affecting the World of Healthcare Practice Healthcare practice and decisions occur within complex social, economic, global and political contexts. (See also Chapters 1 and 7). These contexts reflect a range of influences and trends (Fish and Higgs, 2008), including:

▪ Political trends: ▪ political and strategic environments that are imbued with a general failure to trust and an aversion to risk ▪ a world that is fragmented, complex and uncertain ▪ Global work context trends: ▪ increased emphasis on strategies and operations that are loosely connected and short term ▪ changes in work, communication and service mechanisms linked to the digital revolution, creating ‘unstable, fragmentary conditions’ (Sennett, 2005, p. 3) where constant checking of progress creates instability and difficulty to flourish (O'Neill, 2002) ▪ rising demands for accountability for practice that is fiscally, evidentially and ethically defensible ▪ Communication and information trends: ▪ global mass communication strategies that 75

bring to our urgent attention the latest information and knowledge of practice, technologies, world events and dilemmas ▪ escalating client access to Internet information ▪ Knowledge trends: ▪ exponential knowledge and technological advances ▪ transitory knowledge and the devaluing of history, tradition and practice cultures ▪ Population trends: ▪ demographic changes, particularly aging populations and an increasing number of displaced persons in many areas ▪ changing patterns of disease and disability, changing locations for health services provision, an increased focus on chronic diseases and an increase in the need for complex disease management strategies ▪ Individual/lifestyle trends and expectations: ▪ limited time for individuality, creativity and practice wisdom ▪ increased pressures on healthcare professionals in relation to work and life balance contexts and changing roles and expectations ▪ increased client expectations of quality care and participation in clinical decision making Practice cultures are shaped by their organization's target groups, goals, structures, operational factors like hierarchies and power,

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economic factors, codes of conduct, legal imperatives and size of the organization. Organizations may be local, national or international, government-operated or publicly or privately funded, and they can focus on primary, secondary or tertiary health care. The ongoing debate and pressures from economic versus professionalism imperatives are a key part of institutional healthcare cultures. This debate influences expectations held by clients and colleagues of healthcare professionals but also expectations of the organization as a whole to provide competent and ethical services to clients.

Client Health and Well-Being Narratives and Horizons In this fourth edition of the book, we have devoted a whole section to collaborative clinical reasoning and client input to decision making. This is caused by the changing behaviour and expectations of clients who have much more medical information available to them, the way society is changing (particularly in the West) in relation to the pursuit of health and well-being as a more widespread norm in the face of epidemics like obesity and diabetes, plus changes in professional practice towards greater recognition of the role clients can play in clinical decision making, as informed experts about their own life and health situations. In addition to bringing these horizons to the ‘decision-making table’, patients, particularly those who have chronic conditions, are bringing other perspectives and narratives to their health care that go beyond the biomedical, cure, illness or restitution narrative. People want to replace ‘normal’ with ‘their normal’, ‘the professional as expert and the patient as recipient’ with ‘we both have knowledge to share and perspectives to consider’. And many healthcare clients want to replace ‘my role is a passive, compliant patient’ with ‘since much of my health care is in my own time, I need to be informed so that I can take sound and chosen actions’ (particularly when discharged early, learning to live with chronic disability or illness).

Professional Practice Professional practice and health care deal with many different

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challenges, including wicked problems (Roberts 2000), in a context that looks for accountability and evidence, clarity addresses complex real world problems, human tasks with consequences for life and quality of life and deals with issues associated with sharing decision-making processes and outcomes. Within this arena, professions share a number of common characteristics (the expectation of ethical conduct, operation within professional codes of conduct and societal expectations of competence and professionalism) and are increasingly challenged by the complexities of the human world and the changing physical and technological worlds. Yet each profession has its own culture, including the norms and realizations of practice, standards, language and modes of communication, tools and artefacts of practice implementation and typical locations and situations of operation. Health care comprises a collective of disciplinary and professional cultures and could be thought of as a metaculture in which key norms and ways of being and doing are manifest. For instance, across health care (professions and systems) we recognize the importance of duty of care for individuals and groups participating in health care or living in communities where health promotion seeks to affect individual and population health. The potential of healthcare interventions or restrictions to affect people's lives and well-being is a core dimension of healthcare practice and decision making at broad community and individual levels. Such potential impact demands decisions and decision-making capabilities that are commensurate with quality of life and actions of doing good.

Communities of Practice Professions, such as the health professions, are communities of practice that occur locally, nationally and globally. Practice communities may operate on a profession-specific or interprofessional basis within organizations. In both cases, such communities demonstrate the ability to work collaboratively as a result of shared discourse, language, goals and practices. These shared artefacts and actions constitute dimensions of culture. The term ‘communities of practice’ was developed by Lave and Wenger (1991) to describe a theory of social learning that places

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learning ‘in the context of our lived experience of participation in the world’ (Wenger, 1998, p. 3). Communities of practice are dynamic and flexible as people arrive and leave and as they become more or less central to the practice of the group. Some communities of practice are formally established and managed; others are more organic and evolve, developing shared purposes based on interests or passions. Underpinning this theory are four premises: 1) that people are social beings, 2) that knowledge occurs in relation to valued enterprises, 3) that knowing results from participating and pursuing ability in these enterprises and 4) that learning produces meaningful knowledge. Two key concepts related to communities of practice (Lave and Wenger, 1991) are the following:

▪ Situated learning, which views learning as part of an activity in the world; in that agent, activity and the world mutually constitute each other ▪ Legitimate peripheral participation, which relates to the contention that for newcomers to a practice community, learning through activity happens legitimately from the periphery towards the core of the community of practice as they progressively become full practitioners and members of the practice community, who are integral to the maturing of the field of practice.

Professionalization and Professional Socialization Two core processes lead to the emergence of the practice of professionals within practice cultures. First, there is the sociohistorical process of professionalization that transitioned their occupations into professions. These occupations defined and shaped themselves into auto-regulated, standard-setting, occupational groups with requirements of educational entry and continued membership. Second, there is the process of professional

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socialization. This is an acculturation process involving entry education, reflection, professional development and engagement in professional work interactions; it enables the individual's development of the expected capabilities of the profession and a sense of professional identity and responsibility (Higgs et al., 2009). Novices become members of a particular profession and a unique social group and learn to be part of the culture of that group with all its privileges, requirements and responsibilities. They learn about, and make commitments to, meeting professional and discipline-specific codes of conduct and practice. Professional socialization also refers to the way in which a profession, through its educators, practitioners and leaders, socializes or inducts new members (Higgs, 2013). Professional socialization involves both learning through practice communities and learning to be part of communities of practice. In her research on collaboration in health care, Croker (2011) found that most healthcare professionals engage with multiple practice communities in their work (e.g., their discipline team, their local work area group such as in a specific workplace and their broader professional association). Newcomers need to learn how to relate across each of these groups and communities. A key aspect of professional socialization is the way that students develop working relationships with other practitioners and team members from a range of professions.

Understanding Professional Practice Paradigms We can relate communities of practice and practice cultures to the notion of paradigms wherein a group of practitioners (who could be researchers in a shared research paradigm or professional/clinical practitioners in a shared practice paradigm) come together to pursue common interests and goals. By sharing cultural norms, knowledge and practices, members of the paradigm community function coherently as members of a group who walk, talk and think (reason) in shared, encultured ways. Over time, paradigms evolve their pursuits and methodologies, and their goals often become more refined and effective in relation to the interests

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they serve. Paradigms proliferate, and new ones emerge as interests change or evolve. This means that science (including study of the human and the physical worlds) is not static or confined to a single strategy but responds to changing interests. A key element of learning and working in practice paradigms is recognizing and respecting the profession's practice worldview (or practice ontology) and how that is linked to the way knowledge is determined and created within that practice world (or practice epistemology) (Higgs et al., 2004b) (Box 2.1). Being grounded in their own profession's practice, members of the profession typically work across multiple communities of practice with a range of frames of reference (profession-specific, interdisciplinary, organizational and workplace oriented).

Box 2.1

Ontology and Epistemology – Definitions Ontology: What is? What exists? What types of entities really exist? What is reality (like)? ▪ ‘The theory of existence, or, more narrowly, of what really exists’ (Bullock and Trombley, 1999, pp. 608–609). ▪ A branch of metaphysics, ontology ‘is the science of being in general, embracing such issues as the nature of existence and the categorical structure of reality’ (Honderich, 1995, p. 634). ▪ ‘Derived from the Greek word for being, but a 17th century coinage for the branch of metaphysics that concerns itself with what exists’ (Blackburn, 1994, p. 269). ▪ ‘Ontology comes from the Greek “ontos” meaning being and “logos” meaning logic or rationale, and means literally “the study of being” or “the study of existence” ’ (Everitt and Fisher, 1995, p. 9). Epistemology: What is knowledge? What can we know? How do we know what we know? What counts as true knowledge? ▪ ‘The philosophical theory of knowledge, which seeks to define

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it, distinguish its principal varieties, identify its sources, and establish its limits’ (Bullock and Trombley, 1999, p. 279). ▪ The branch of philosophy, epistemology ‘is concerned with the theory of knowledge. Traditionally, central issues in epistemology are the nature and derivation of knowledge, the scope of knowledge, and the reliability of claims to knowledge’ (Flew, 1984, p. 109). ▪ ‘The term derives from the two Greek words, “episteme” meaning knowledge and “logos” meaning logic or rationale. In modern English, epistemology means the theory of knowledge’ (Everitt and Fisher, 1995, p. 1). Table 2.1 presents a categorization of three practice paradigms (the empirico-analytical, interpretive and critical paradigms) informed by Habermas' concept of interests. According to Habermas (1968/1972) our interests, while often hidden, reflect our specific viewpoints and values and are the motivational aspect of our inquiries and action. Our interests are expressed in our knowledge (which is an activity rather than a static phenomenon) and are evident in the types of questions we ask and the strategies that we apply to search for responses to these questions. Habermas differentiated three interests: technical, practical and emancipatory interests (see Table 2.1). Habermas (1968/1972, p. 308) contended that: TABLE 2.1

Practice Paradigm

Practice field

Interests

Ontology

Practice Paradigm EmpiricoAnalytical Paradigm Natural Sciences Biomedicine Technical Cognitive: Prediction Objective Evidence Positivist/empiricist

HistoricalCritical Paradigm Hermeneutic/Interpretive (Critical Science) Paradigm Social Sciences Critical Science Wellness-oriented Collaborative health care health care Practical Cognitive: EmancipatoryFinding understanding, Cognitive: Mediation, Consensus Transformation Emancipation Social constructivist

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Historical Realism:

Approach to defining reality

Epistemology (nature and construction of knowledge)

ontology: the world is objective and lawful; it exists independently of the knowers

To positivists knowledge arises from the rigorous application of the scientific method

ontology: reality is socially constructed Hermeneutic ontology: people are being in the world of social practices and historical contexts In the interpretive paradigm, knowledge: comprises constructions arising from the minds and bodies of knowing, conscious and feeling beings and is generated through a search for meaning.

Methodological Controlled tools Observation

Understanding meaning, Interpretations of texts

Knowledge product

Intersubjectively Negotiated Meaning

Facts Truths

Evidence and expertise

Best available external evidence

Individual practice expertise

Practice

Practice is characterized as objective, pure, accountable

Practice is characterized as subjective, emotional, risky

history, social practice and culture shape practice

In the critical paradigm, knowledge: is emancipatory and personally developmental, requires becoming aware of how our thinking is socially and historically constructed Self-reflection, group critical reflection Critique of natural and social influences Negotiated understanding Respect for expertise of all parties Practice is characterized as collaborative, respectful, selfchallenging and transformative

Based on Higgs, Trede and Rothwell, 2007, and Higgs and Trede, 2010

The approach of the empirical-analytic sciences incorporates a technical cognitive interest, that of the historical-hermeneutic sciences incorporates a practical one (and emanates from a concern for understanding); and the approach of critically oriented sciences incorporates emancipatory cognitive interest.

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In Table 2.1, the three paradigms are interpreted according to the practice field, interests, ontology, epistemology, methodological tools, knowledge product, evidence and expertise and the mode of practice they epitomize. Across the health sciences, practitioners may work in areas that are typically based on the biosciences (e.g., pathology, practices that support the cure and restitution narrative), a wellness orientation (e.g., occupational therapy, narratives based on client-led ability rather than disability narratives) and collaborative health care focussed on rejection of taken-for-granted rules and practices. Practitioners who want to work deliberately in these paradigms need to pursue practice ontologies and practice epistemologies that match their paradigms. They need to understand these practice philosophy underpinnings and make them part of their being (practice ontology), knowing (practice epistemology), doing (practice embodiment), thinking (practice reasoning) and becoming (practice development). In this way, practitioners develop and own their personal ontologies and epistemologies:

▪ Personal ontologies refers to being in practice and owning and embodying an ontological worldview. The ontological turn involves a shift away from technical rationality and intellectual (cognitive) capacity towards being and becoming in practice. ‘This turn is primarily based on the assumption that the knowledge and skills that will be needed in future workplaces cannot be known, in advance, in detail or with any great certainty; thus, attention to “knowing the world” and “skills for doing” appears to be an unproductive focus for educating future professionals in higher education. Rather, “being in the world” – pulling disparate elements of practice together into one “assemblage of self” – needs to be at the centre of university teaching’ (Markauskaite and Goodyear, 84

2017, p. 54). ▪ Personal epistemologies: Epistemology as a broad concept (Barton and Billett, 2017) refers to the nature and origins of knowledge and encompasses how knowledge is derived, tested and validated. Personal epistemology is about people's way of knowing and how they build their knowledge base from prior experiences and through their capacities and ongoing negotiations. Such knowledge bases evoke readiness for practice, learning and reasoning, but they can also inhibit these activities if they are narrow or unchanging. Loftus (2009) identified the substantial influences of sociocultural factors and the personal history and socialization experiences of individual practitioners and students on the way they understood what knowledge is and how they use and name it in practice. Further depth of information on ontological and epistemological underpinnings of different practice approaches is provided in Box 2.2.

Box 2.2

Ontologies and Epistemologies Ontological or worldview perspectives differ across the practice paradigms (see Table 2.1). ▪ In the positivist/empiricist ontological tradition, the world is objective, because it is said to exist independently of the knowers, and it consists of phenomena or events that are orderly and lawful.

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▪ In the constructivist view, knowers are seen as conscious subjects separate from a world of objects; subjects who use knowledge who have theories about their practice and who behave according to tacit rules and procedures. Multiple constructed realities are recognized to occur (i.e., different people have different perceptions of reality through their attribution of meaning to events, meaning being part of the event not separate from it) (Lincoln and Guba, 1985). ▪ The social constructivist view contends that reality and knowledge are socially constructed. Reality exists because we give meaning to it (Berger and Luckmann, 1985). Different cultures have different social constructions of reality. Within the interpretive tradition, the world and reality are interpreted by people in the context of historical and social practices. ▪ The hermeneutic view arises from the ideas of Heidegger (1962), Merleau-Ponty (1956) and Gadamer (1975). In this hermeneutic view, there is no subject/object split; people are seen as part of the world, being in it and coping with it. They are also seen as beings for whom things have significance and value, having a world of social practices and historical contexts and as being a person in time (Leonard, 1989). This view of people and the world is a relational one (Benner and Wrubel, 1989). Unlike the constructivist view of knowledge, this knowing has no mental representation and may be embodied, that is, known by the body without cognition. ▪ The (historical) realist is concerned with social structures and how macro- and micro-political, historical and socio-economic factors influence our lives. Epistemological perspectives or stances within research paradigms are portrayed as follows: ▪ To positivists or empiricists, knowledge arises from the rigorous application of the scientific method and is measured against the criteria of objectivity, reliability and validity. In the empirico-analytical paradigm, knowledge: is discovered, i.e., universal and external truths are grasped and justified, arises from empirical processes which are reductionist, value neutral,

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quantifiable, objective and operationalizable; statements are valid only if publicly verifiable by sense data. ▪ The idealist approaches of Dilthey (1833–1911) and Weber (1864–1920) focused on interpretive understanding (Verstehen), accessing the ideas and experiences of actors, as opposed to the explanatory and predictive approach of the physical sciences (Smith, 1983). This perspective results in a focus on human behaviour as occurring within a context and the understanding or knowledge of human behaviour as requiring an understanding of this context. ▪ Constructivists view knowledge as ‘an internal construction or an attempt to impose meaning and significance on events and ideas’. In this perspective, each person constructs a more-orless idiosyncratic explanatory system of reality' (Candy, 1991, p. 251). ▪ The social constructionist approach (McCarthy, 1996) construes knowledge as a changing and relative phenomenon and examines the social and historical constructs of knowledge in terms of what knowledge is socially produced and what counts as knowledge. ▪ The (historical) realist is concerned with how we understand our lives in the context of socio-cultural, historical influences. Knowledge is always influenced by social interest, and it is not grasped or discovered but is acquired through critical debate. In the critical paradigm, knowledge: is emancipatory and personally developmental; requires becoming aware of how our thinking is socially and historically constructed and how this limits our actions; enables people to challenge learned restrictions, compulsions or dictates of habit; is not grasped or discovered but is acquired through critical debate; and promotes understanding about how to transform current structures, relationships and conditions that constrain development and reform (Higgs and Titchen, 1995).

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Practice and knowledge are reciprocal elements; each forms part of the composite culture of professional practice. One of the responsibilities of professionals is to understand and critique the knowledge they use in practice. Professional knowledge is embedded in and arises from the context of professional practice, particularly the history of ideas and the knowledge of society (Higgs et al., 2004). The development of practice knowledge occurs within a variety of contexts including the historical era and the cultural, social and individual perspectives of practitioners, scholars and researchers engaged in the exploration of practice and practice knowledge. Professions evolve in sociocultural, political and historical frames of reference. Traditionally, Western thought has been dominated by the Cartesian notions that reasoning and knowing are essentially activities of individuals operating in isolation. Vygotsky (1978, 1986) and Bakhtin (1986) have challenged this idea. They argued that reasoning and knowing begin as activities embedded in social interaction, and they are primarily intersubjective processes arising within cultures. We become acculturated into societies that provide us with a cognitive toolkit of knowledge and ways of using such knowledge. Professional education and training are primarily about socializing students into particular ways of knowing and thinking about the world of practice. In Vygotskian terms, professional ways of thinking and knowing are higher mental functions. Vygotsky (1978) claimed that higher mental functions, which would include clinical reasoning, are qualitatively different from lower mental functions and cannot be reduced to them. Higher mental functions need a different conceptual framework, one that takes into account their cultural and historical nature.

Professional Practice Knowledge Professional practice knowledge evolves as a consequence of the critical use and reflection on the profession's knowledge and practice by individual professionals and the profession collectively. The exploration of the history of ideas (see Berlin, 1979) within a practice can assist practitioners to contextualize their understanding of contemporary practice and enhance their ability to develop their knowledge and practice effectively. The discipline of the history of

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ideas was popularized by the American philosopher Arthur Lovejoy (1873–1962) in the 1920s (Kelley, 1990). The term ‘history of ideas’ encompasses approaches to study that centre on how the meaning and associations of ideas change according to history (Burke, 1988). Lovejoy (1936) argued that we understand ourselves better by understanding the ways in which we have evolved, or the manner in which we have come, over time, to hold the ideas that we do. History needs to be concerned with ideas that attain a wide diffusion and to cross barriers between different disciplines and thinking, recognizing the fact that ideas that emerge at any one time usually manifest themselves in more than one direction (Lovejoy, 1936). A history of ideas approach allows us to understand the origins of ideas and place our own ideas in perspective (Adams, 1987). Learning, both formal and self-directed, involves understanding the way that knowledge of the discipline is created and used in practice. Epistemology and disciplinarity are related; both are concerned with knowledge and the adaptation of knowledge in particular situations of practice (Barton and Billett, 2017). Building disciplinary knowledge similarly requires this understanding and a recognition of how knowledge in the discipline and practice community is created, tested and validated. Table 2.2 provides an overview of different ways of categorizing knowledge. This work illustrates how important knowledge is in practice and how much work over time has been spent by many scholars in recognizing different ways knowledge is created and used in practice. We need multiple forms of knowledge, including the scientific knowledge of human behaviour and body responses in health and illness, the aesthetic perception of significant human experiences, understanding of the uniqueness of the self and others and their interactions and an appreciation of morality and ethics. According to Kemmis and Smith (2008, p. 4), praxis ‘is action that is morally-committed and oriented and informed by traditions in a field. It is the kind of action people are engaged in when they think about what their action will mean in the world. Praxis is what people do when they take into account all the circumstances and exigencies that confront them at a particular moment and then, taking the broadest view they can of what it is best to do, they act’. Clinical reasoning is embedded in praxis. In the model in Table 2.2, praxis is

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seen as a core aspect of advanced practice because of the expertise required to engage deeply in praxis and because it epitomizes practice that embodies ethics and morality, as well as professional capabilities. TABLE 2.2

Knowledge Categorizations Plato (400 BC) (P) Aristotle (300 BC) (A) (in Gustavsson, 2004)* Epistêmê (P) (A) Objective knowledge, represents scientific knowledge, theoretical knowledge

Vico (in Berlin, 1979)

Kolb (1984)

Deductive knowledge: things that are true either by definition or by deduction from propositions or assumptions that are themselves true purely by definition Scientific knowledge requires objectively valid, reliable and reproducible evidence. Only evidence gained by the senses, through observation, description and measurement, may be counted. Knowledge remains ‘true’ only for as long as it is not objectively refuted; when it fails the crucial test, it becomes

Carper (1978) Sarter (1988) Interpretive knowledge (philosophical analysis)

Empirical knowledge

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Reason and Heron (1986)

Propositional knowledge: knowledge of things, gained through conversation, reading, etc.

obsolete, to be replaced by a superior formula/findings. Téchnê (A) Experiential Knowledge knowledge is used in the gained by process of personal producing, experience. Some manufacturing crucially and creating important products human knowledge exists Phrónêsis (A) that is distinct Practical knowledge or from and not reducible to wisdom used in the process either scientific or deductive of social knowledge interaction; incorporates ethical understanding of the values and norms that help people frame their ideas of a good life

Experiential knowledge: concrete experience, reflective observation, abstract conceptualization, active experimentation

Aesthetic knowledge (artistic) pattern of knowing, derived from experience Personal pattern of knowing self Ethical (moral) pattern of knowing

Nonpropositional (a) Experiential knowledge from direct encounters with persons, places/things (b) Practical knowledge gained through activity and related to skills or competencies

Based on Higgs, Jones and Titchen, 2008

Developing Intellectual Virtues Another way of revealing advanced and deliberately known practice is via Aristotle's (trans., 1999) three intellectual virtues or excellences of mind:

▪ Epistêmê is an intellectual virtue characterized as scientific, universal, invariable, contextindependent knowledge. The concept is reflected in the terms epistemology and epistemic. ▪ Téchnê refers to craft or applied practice; it is an 91

intellectual virtue characterized as contextdependent, pragmatic, variable, craft knowledge; it is governed by a conscious goal, and it is oriented towards practical instrumental rationality. The concept is reflected in terms such as technique, technical and technology. ▪ Phrónêsis refers to practical wisdom; it is an intellectual virtue characterized by values and ethics. It involves value-based deliberation and practical judgement. It is reflective, pragmatic, variable, context-dependent and action-oriented. These ways of knowing provide a useful point of reflection on reasoning in practice – what it is and what it can be, when knowingly practiced. These virtues ask learners and practitioners to think deeply about what knowledge is, how it links to professionalism and how knowledge, reasoning and action combine in practice and to engage with these ways of knowing, doing, being and becoming in practice. (Refer to practice as doing, knowing, being and becoming in: Higgs, 1999; Higgs and Titchen, 2001.)

Epistemic Cultures According to Nerland and Jensen (2014, in Nerland 2016, p. 137) ‘professions can be regarded as distinct knowledge cultures, constituted by a set of knowledge processes and practices that define expertise in the given area and serve to distinguish professional practitioners from other actors’. To contend with the challenges related to knowledge and practice conventions faced by professional communities today, argued Nerland (2016), we need a perspective that accounts for multiple and dynamic dimensions of knowledge. This would involve adopting a critically reflexive approach to the use and development of knowledge processes and development practices. Knorr Cetina (2007) contends that different expert cultures produce knowledge in distinctly different ways, and she introduced

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the concept of epistemic cultures to represent the way that such expert and professional cultures generate and use their knowledge. She uses the term ‘machinery of knowledge construction’ to encompass sets of practices, arrangements and mechanisms bound together by necessity, affinity and historical coincidence, which, in a given area of professional expertise, make up how we know what we know (Knorr Cetina 2007, p. 363). The notion of epistemic culture is a rich and deep way of understanding the worlds of practice and how the discourse of practice knowledge and knowledge-grounded practice cohabits these worlds symbiotically. Epistemic cultures comprise both knowledge as practiced and the disciplinary, expert-framed and social cultural settings in which knowledge and practices interact for the benefit of the participants in these cultures. Professional cultures are thus enacted and embodied through the group or profession and by individual practitioners. This enactment involves a critical living dialogue that occurs among practice knowledge, practice actions and practice reasoning, with each of these three existing as evolving dimensions of living practice in changing social practice arenas.

Epistemic Fluency Beyond and within epistemic cultures, we come to the idea of epistemic fluency (Goodyear and Zenios, 2007). Goodyear and Ellis (2007) build on the work of Morrison and Collins (1996, p. 109), who provide Collins' key terms: epistemic forms to refer to ‘target structures that guide inquiry’ and epistemic games to refer to ‘sets of moves, constraints, and strategies that guide the construction of knowledge around a particular epistemic form’. Epistemic forms include taxonomies, models and lists. Engaging in epistemic games in one's own disciplinary field (and others) helps build capacity to perform strategies linked to the inquiry structures of that field and others; the latter helps the learner to gain an appreciation of how others develop and use knowledge. The concept and practice of epistemic fluency is described by Markauskaite and Goodyear (2017, p. 1) as follows: ‘people who are flexible and adept with respect to different ways of knowing about the world can be said to possess epistemic fluency’. The idea of

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fluency, typically applied to language, the spoken word and interactive communication, is particularly useful when thinking about knowledge and clinical reasoning. First, it refers to having a command of the language, and experienced practitioners with advanced clinical reasoning capabilities need to have this ability. Technical language provides the means and tools for communicating with colleagues using the rich knowledge and shared understanding embedded in discipline-specific and generic healthcare language. It is used to record notes in patient histories, write reports to referring practitioners, record information for legal or historical records and present new ideas such as research findings for the critical appraisal of the professional and scientific communities. Interpersonal (professional) language is a means for performing the actions of practice such as taking a patient's history and seeking feedback about changes in symptoms during treatments, a way of sharing viewpoints and discussing treatment options and a tool for communicating findings, decisions, diagnoses and so on. Linking this fluency to knowledge construction and coconstruction and the derivation of knowledge from practice, we can recognize the way that clinical reasoning and decision making rely on epistemic fluency. Both reasoning and decision making involve understanding knowledge, appreciating different ways of knowing, using different sources and forms of knowledge in reasoning and placing different knowledge (including client's knowledge) as the influences and benchmarks that drive and determine decisions. We can think of epistemic fluency within clinical reasoning as a capability that is most clearly demonstrated by experienced and expert practitioners. Overall practice capability requires clinical reasoning fluency.

Developing Epistemic Fluency and Reasoning Conversation Capability If we acknowledge that living cultures exist in health care, we recognize that culture requires communication, and decision making requires conversations. At the very least, these practice conversations involve the ascertainment of patients'/clients' needs/goals/expectations and practitioners'/professionals' expert

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input to decision making and treatment advice. Frequently professional practice also involves conversations and collaborative decision making among practitioners who share ‘case management’ responsibilities. Ideally, practice involves conversations that incorporate and respect the multiple cultures, expert and selfknowledge perspectives of the decision-making participants (including clients/patients and carers) and the perspectives and prerogatives of each player. In this way, rich collaborative clinical decision making is both encultured and conversational.

Pursuing Clinical Reasoning Capability Too often clinical reasoning is simply thought of as a process of thinking or a set of decisions that need to be made. Instead, clinical reasoning needs to be recognized as capability, indeed, as a set of capabilities. Capability refers to practice-grounded ability that is demonstrable and justifiable (Stephenson, 1998); it goes beyond technical competence and encompasses agency, ingenuity and confidence in actions including decision making, problem identification and problem solving. Capability places emphasis on being able to perform well in both known and unknown contexts and the capacity to solve complex and more straightforward clinical problems. Capability is required in both task and relationship aspects of practice, in working effectively with others and confidence in the ability to navigate unfamiliar circumstances and learn from these experiences. ‘Capability is a holistic concept which encompasses both current competence and future development through the application of potential. The concept is applicable across both individuals and organisations’ (Cairns and Stephenson, 2009, p. 16). The three key elements of capability are ability (current competence and perceived potential), self-efficacy (confidence in capacity to perform tasks) and values (particularly the way actions in uncertain conditions are guided by values and the capacity to articulate values). ‘Capability (encompasses):

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▪ the capacity to operate in both familiar and unfamiliar circumstances ▪ the utilization of creativity and imagination/innovation ▪ being mindful about change and open to opportunities/uncertainties ▪ being confident about one's abilities ▪ being able to engage with the social values relevant to actions ▪ engaging with learning as a self-directed process ▪ operating to formulate and solve problems'. (ibid). In the re-interpretation of clinical reasoning presented in this chapter, clinical reasoning is viewed as a set of capabilities that are cognitive, embodied, owned, collaborative and critical. Each of these words reminds us of the contexts, cultures, communities and challenges that have been presented earlier, and they epitomize the essential responsibilities of professionals to draw all of their knowledge, reasoning and technical capabilities together in practice that is of high quality in conditions of uncertainty and conditions of greater simplicity, whether these situational dimensions are caused by the inherent nature of the practice-reasoning task, setting, decision making practice or the setting. The idea of capability is strongly supported in education and other forms of practice. Eraut (2000, p. 128), for example, identifies capability as a core element in choosing an appropriate cognitive approach in given situations. He raises the question ‘What factors are likely to affect the mode of cognition employed by a particular practitioner in a particular context?’ The answer, he argues, includes:

▪ task factors: evidence, complexity ▪ practitioner factors: capability and disposition ▪ contextual factors: time available and the 96

crowdedness of the situation (the number of clients, activities, pieces of information and so on that are competing for the practitioner's attention. Eraut contends (ibid) the following:

▪ An analytic approach is appropriate where there is ‘sufficient research evidence available in which the practitioner has confidence, the problem being capable of being represented in a form which enables it to be “solved” mainly on the basis of that evidence, and the practitioner being willing and able to do the analysis and implement the results’. ▪ An intuitive approach is appropriate when ‘the practitioner has considerable experience of similar situations’. ▪ A deliberative approach is appropriate when the practitioner ‘has both some evidence and some relevant experience, a willingness to reflect and consult and a sense of what is possible under the circumstances’. Fig. 2.1 draws together the arguments presented earlier, in an interpretation of clinical reasoning capability built around an encultured view of clinical reasoning that is embodied and enacted in healthcare professional practice.

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FIG. 2.1 Clinical reasoning capability.

The evolution of clinical reasoning capability requires practitioners to pursue a deep understanding of reasoning as a complex arena of practice, to recognize the inherent contextualization of clinical reasoning, to value different approaches to reasoning suited to the reasoner's learning readiness, to develop advanced ability and fluency in the language and articulation of reasoning with diverse clinical decision-making partners and to employ learning strategies that draw each of these abilities and understandings into practice.

Reflection Point 2 How do you interpret each of the dimensions and considerations of capability presented in Fig. 2.1? Do they feature in your reasoning practices?

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ReDefining Clinical Reasoning as A Range of Encultured Decision-Making Capabilities In this section, I present my model and definition of clinical reasoning and decision making reconceptualized as a set of encultured decision-making capabilities. This definition and model build on my 20 years of extensive research and scholarship on clinical reasoning. This research has been challenged, filtered and re-interpreted through the process of producing the four editions of this book since 1995 and through an extensive program of research and scholarship involving a team of doctoral students, colleagues and postdoctoral fellows. Of particular interest in my research and education have been the nature of practice knowledge, multiple ways of knowing, communities of practice, the symbiosis of practice knowledge and research, philosophical views of knowledge and practice and the power of the lenses of capability and enculturation. International leaders in clinical reasoning research, scholarship and education have debated with me about the nature of clinical reasoning and how it operates in and emerges from practice. These rich debates have enriched my journey of understanding of this fascinating and vital component of professional practice.

A Revised Interpretation of Clinical Reasoning and Decision Making Clinical reasoning is a multilayered, context-dependent way of thinking and decision making in professional practice that is embedded and enacted in healthcare professional practice through epistemic-ontological cultures. The purpose of clinical reasoning is to make sound, client-centred decisions (preferably with clients), guide practice stances, actions and trajectories and optimize client health and well-being choices, pathways and outcomes. Its key dimensions are the generation and use of practice knowledge, reasoning capabilities and metacognition. It involves metaskills of reflexivity, knowledge generation

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through practice, ongoing learning and reasoning refinement, practice model authenticity (see Chapter 4), constructed narratives and critical, creative conversations. The construction of narratives helps make sense of the multiple factors and interests pertaining to the current reasoning task. The pursuit of conversations among colleagues, clients and carers helps construct client-optimal decisions and particularized healthcare pathways. Such ‘conversations’ occur when clinical reasoning is viewed as a contextualized interactive phenomenon rather than a specific process. Practitioners interact both with the task/informational elements of decision making and with the human/collaborative elements and the interests of the various decision-making participants. These conversations involve interactions based on critical appraisal of circumstances and, where possible, critical interests in promoting emancipatory practice and the creation and implementation of particularized, person-centred healthcare programs. It is framed by, and embodied in, the epistemic (knowledge) and ontological (worldview) cultures of practice communities, professionalism, ethical codes of practice, community and client expectations and the needs and perspectives of its participants. It occurs within a range of problem spaces (see Chapter 3) and contexts framed by the unique frames of reference (interests, knowledge, abilities, values, experience) of the practitioners, patients/clients, carers and organizations involved. It draws on evidence to support decision making that takes a range of forms and importance including clinical data, experiencebased illness scripts, (qualitative and quantitative) research findings, theoretical arguments and professional experience theorizations (Higgs, 2017; 2018). It incorporates judgement and decision making at micro (e.g., deciding on next steps, interpreting observed symptoms), macro (e.g., making and producing diagnoses, treatment plans) and meta (e.g., metacognitive critique of decisions in action, evaluation of proposed actions and outcome suitability and quality) levels. Judgement is both a verb (practice, process) and a noun (product and responsibility). It may be individually or collaboratively conducted. Teams are often interdisciplinary and ideally involve the client (and carers).

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Shared reasoning and decision making values the different inputs (knowledge, interests, perspectives) that each player brings to decision making, particularly the client. Advanced clinical reasoning involves moving beyond the acts of clinical decision making through the pursuit of epistemic and ontological fluency and the informed use of the language of clinical reasoning across cultures, to enhance clinical reasoning in action as an embodied, reflexive and interactive capability that is realized through clinical decision-making conversations.

A Model of Clinical Reasoning as Encultured Decision-Making Capabilities This model (Fig. 2.2) is framed by four influence factors:

FIG. 2.2 Encultured clinical decision-making

capabilities.

▪ the task facing the decision maker(s) (left side) – 101

ranging from highly complex, challenging tasks to straightforward tasks. In the centre of this continuum lie fluctuating tasks. ▪ the ‘scene’ or context (right side) – ranging from highly fluid settings where multiple factors influence the decision-making challenge to stable, predictable situations. In the centre of this continuum lie changeable situations. ▪ the decision-making approach (upper continuum) – ranging from discipline-based, autonomous approaches to life-based, interdependent approaches. ▪ the decision makers (lower continuum) – ranging from individual and teams of professionals who lead the clinical decision making to communitybased decision-making groups (including practitioners and clients). There are five decision-making approaches with colours assigned to reflect the approach:

▪ WHITE (Novice) Decision Making – this approach matches the demands of (more) straightforward reasoning tasks in relatively stable and predictable settings. It is typical of novices who adopt a deliberate, explicit, studied approach to reasoning (e.g., hypothetico-deductive reasoning) and work individually or in professional teams; it relies on emerging disciplinary knowledge. This approach draws on téchnê and epistêmê intelligences. ▪ PURPLE (Expert) Decision Making – this approach matches the demands of (more) complex 102

and challenging reasoning tasks in relatively fluid settings influenced by multiple factors. It is typical of acknowledged, expert clinical reasoners who adopt a complex reasoning approach to reasoning (e.g., pattern recognition) and the use of instantiated scripts (see Boshuizen and Schmidt, 1992) and deep rich knowledge bases. They work individually or in professional teams. This approach draws on epistêmê and the embedded ethicality and depth of embodied practice or praxis. It demands high-level fluency and rich technical, professional, critical, epistemic, ontological and interpersonal capability. ▪ ORANGE (Co-constructed) Decision Making – this approach emphasizes the demands of recent times, where clients are better informed and agentic than ever before. It can work well within the demands of (more) straightforward reasoning tasks in relatively stable and predictable settings. It may involve decision making with individual clients, groups or communities. The key element that influences this approach is co-constructed and interdependent decision making, aiming to pursue life-based rather than clinically oriented decisions. This approach draws on téchnê and phrónêsis. It requires a willingness to share expert knowledge and capabilities with clients and a commitment to valuing the perspectives and input of others. ▪ GREEN (Ecological) Decision Making – this approach matches the demands of (more) complex and challenging reasoning tasks in relatively fluid 103

settings, influenced by multiple factors. It is typical of highly experienced but nontraditional practitioners who focus on the complexity of practice and community settings where individuals or groups of clients are looking for different narratives and solutions. The term ecological has been attached to this approach to highlight the interdependence of the decisionmaking parties and the need for mutual respect among them for their different perspectives and contributions. The processes of ‘green’ decision making are inherently dynamic and emergent. This approach draws on a strong ability in phrónêsis and the embedded ethicality and depth of embodied practice or praxis. It demands highlevel (individual and collective) epistemic and ontological fluency and rich critical, technical, professional, epistemic, ontological and interpersonal capability on the part of practitioners and a willingness to share expert knowledge and capabilities with clients and a commitment to valuing the perspectives and input of others to realize optimal solutions to the challenges posed. Networking of decision-making participants is a key feature of this approach to decision making. ▪ SILVER (Mercurial) Decision Making – is placed at the centre of the four continua, deliberately emphasizing that some decision-making approaches need to be highly versatile, reflexive and dynamic. This approach draws on epistêmê, 104

phrónêsis, téchnê and praxis in varying ways, depending on the task, setting, practice and players. The approach is included in this model to recognize that clinical decision-making situations and players are not static, and the approaches adopted need to be knowingly responsive to these changes – or at times driving context changes. This approach demands a high level of reflexivity, versatility, fluency and rich technical, professional, critical, epistemic, ontological and interpersonal capability; a willingness to share expert knowledge and capabilities with clients; and a commitment to valuing the perspectives and input of others.

Chapter Summary Clinical reasoning is a sophisticated set of reflexive, encultured capabilities that are deeply contextualized in the reasoner's discipline, their ways of knowing, their owned practice model and in their work setting across multiple communities of practice. Somewhere on the journey from learning clinical reasoning as a systematic, conscious, risk-managed, novice-oriented process to the highly attuned wise practice of professional experts, practitioners should come to appreciate clinical reasoning as the most critical, integrative dimension and capability of professional practice.

Reflection Point 3 What insights have you gained about clinical reasoning and decision making from this chapter? How might these insights influence your reasoning and practice?

References 105

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3

Multiple Spaces of Choice, Engagement and Influence in Clinical Decision Making Joy Higgs, Mark Jones

CHAPTER AIMS The aims of this chapter are to: ▪ recast clinical reasoning spaces from the inside out, ▪ examine reasoning strategy choices and ▪ reflect on professional development implications for the practitioner-asreasoner.

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KEY WORDS Clinical reasoning approaches Problem spaces Choices Engagement

ABBREVIATIONS/ACRONYMS HDR Hypothetico-deductive reasoning

Introduction Clinical decision making involves people, information, evidence, goals and connections. Each of these elements of decision making operates in situations that could be thought of as spaces where choices, engagement and influences interact. In this chapter, we explore these elements using a model of these decision-making actions, engagement and influences in spaces viewed from the inside out.

Clinical Reasoning Spaces From the Inside Out Clinical reasoning could be interpreted as operating in spaces in which different clinical situations are considered, healthcare problem needs or issues are addressed, particular influences are experienced and unique sets of people are engaged in providing client care. Kassirer et al. (2010, p. 311) define the problem space as ‘the subject's representation of the task environment that permits the consideration of different problem solutions and sets limitations on possible operations that can be applied to the problem; a sort of maze of mental activity through which individuals wander when searching for a solution to a problem’. In Fig. 3.1, we can see a number of these clinical reasoning spaces from the inside out. At the centre are the core players, the client and the clinician, addressing the client's clinical needs/problems.

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Moving outwards, this core team is joined by other people who play a role in the client's care: the healthcare team, carers and other support people such as community services agencies. Many factors influence all of these core and surrounding interactions. These are discussed in Chapter 1 and across the various Section 2 chapters.

FIG. 3.1 Clinical reasoning spaces from the inside out.

Client Spaces In this book we have elected to use the term ‘client’ instead of ‘patient’ to encompass many different roles clients/patients follow and the different approaches to care across different agencies and professions. The role for the client as a consumer of health care is radically different in many respects from the dependent patient role of traditional medicine, where ‘autonomy’ of healthcare professionals was manifest as maximum control over clinical decision making and clinical intervention. Consumers of health care are becoming increasingly well informed about their health and about healthcare services. Self-help and holistic health care are

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becoming more central to health care, and the goal of achieving effective participation by consumers in their health care is widespread, requiring healthcare professionals to diminish their decision-making authority and involve their clients actively in clinical decision making when possible. Increasingly, clients’ choices, rights and responsibilities in relation to their health are changing. For some time, people have advocated client involvement in decision making about the management of their health and well-being. Payton et al. (1990), for instance, argued that this process of client participation is based on the ‘recognition of the values of self-determination and the worth of the individual’ (p. ix). Using understanding of their clients’ rights and responsibilities, clinicians need to develop their own approaches to involving the client in reasoning and decision making. Mutual decision making (see Section 3 chapters) requires not only a sharing of ownership of decisions but also the development of skills in negotiation and explaining to facilitate effective two-way communication. Professional autonomy becomes redefined as independence in function (within a teamwork context) combined with responsibility and accountability for one's actions (including the sharing of decision making). An important aspect of involving patients/clients in clinical decision making is determining and facilitating their appropriate level of participation and responsibility. A level of participation in clinical reasoning appropriate for the individual has been demonstrated to contribute to the client's sense of control; in this process it is important to ensure that the client's input is voluntary and the client is informed of the inherent uncertainties of clinical decision making (Coulter, 2002). The problem space of clients plays an important role in the process of clinical reasoning because it affects framing, naming and dealing with their healthcare needs and concerns; it comprises:

▪ the personal context of individual clients, which incorporates such factors as their unique cultural, family, work and socioeconomic frames of reference and their state of health. Each of these factors contributes to clients’ beliefs, values and 116

expectations and to their perceptions and needs in relation to their health. ▪ the unique multifaceted context of clients’ healthcare needs. This includes clients’ health conditions and their unique personal, social and environmental situation. Clinical problems can be ‘confusing and contradictory, characterized by imperfect, inconsistent, or even inaccurate information’ (Kassirer and Kopelman, 1991, p. vii). ▪ For clients who are seeking health-promotion solutions, healthcare professionals face the task of identifying and dealing with multiple personal and environmental variables to produce an optimal client-centred solution. ▪ The nature of the clinical practice world, which is complex, typically with time pressures and constrained by contextual factors.

Practitioner Spaces Practitioners bring their personal and professional selves to the task of clinical decision making; these selves frame their problem space. As well as functioning within their personal frames of reference, practitioners operate within their professional frameworks (e.g., the ethical and competency standards/requirements of their profession) and within a broader context of professionalism. The term health professional implies a qualified healthcare provider who demonstrates professional autonomy, competence and accountability (Higgs, 1993). Professional status incorporates the responsibility to make unsupervised and accountable clinical decisions and to implement ethical, competent and person-centred practice. This requires healthcare professionals to consider the client's problem space, as described earlier, and to make decisions about the client's level of involvement. Dealing with ill-structured

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healthcare problems requires high-level clinical reasoning abilities, increasingly refined and elaborated medical and profession-specific knowledge (Schmidt et al., 1990) and judgement (Round, 2001). In relation to ethical issues, practitioners need the ability to deal with these matters in person-centred, professional ways. In addition, practitioners’ problem spaces include their individual philosophical paradigms and approaches to practice (see Chapter 3), their clinical reasoning capability, and clinical reasoning expertise (see Chapters 4 and 5).

The Collaborative Problem Space of the Team Most healthcare professionals work in collaboration with other team members, either directly or indirectly via referral. This includes work across mainstream and complementary and alternative medicine. Byrne (1999) suggested that a coordinated and integrated approach to care is particularly important in the management of chronic and complex health problems. Similarly, Grace et al. (2006) identified an increasing preference in clients with chronic health problems, particularly those dissatisfied with mainstream medicine, for practices that directly integrate complementary and alternative medicine with general practice; such models, they found, worked best for clients when both practitioners worked in collaboration. Another area in which multidisciplinary health care has been found to be beneficial and widespread is chronic pain management (Loftus and Higgs, 2006). The level of collaboration in clinical decision making in these settings varies considerably. Practitioners may make decisions separately and report decisions to others (e.g., via client records); they may refer clients to others to take over client care or to receive advice; they may operate as a decision-making team making decisions on behalf of their clients; or they may work with clients as members of the decision-making team. Croker and Higgs (2016) reminded us that practitioners are often members of multiple teams with different agendas and modes and roles of decision making.

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Reflection Point 1 Consider the changes you make to your practice and your ways of engaging with clients if you are working solo with the client or working in a team.

The Problem Space of the Workplace and the Local System Clinicians frequently face ill-defined problems, goals that are complex and outcomes that are difficult to predict clearly. Many aspects of the workplace influence clinical decision making, particularly levels of available human, material and economic resources. Many factors in the workplace frame our approaches to our practice of clinical reasoning. Funding pressures create ‘clinical practices whose explicit demands are heavily weighted toward management and productivity rather than diagnosis and understanding’ (Duffy, 1998, p. 96). Such practices are not conducive to reflecting on our understanding of practice. Further, misinterpretations of what evidence-based practice really requires (see Reilly et al., 2004) means that some clinicians do not use clinical reasoning critically and wisely to assess evidence for its applicability to individual clients (Jones et al., 2006a, 2006b).

The Knowledge-Reasoning Space of Clinical Decision Making Three considerations are pertinent in considering this knowledgereasoning space. First, professional judgement and decision making within the ambiguous or uncertain situations of health care are an inexact science (Kennedy, 1987). Checkland (1981) refers to ‘soft systems’ (like healthcare systems) as those in which goals may be unrecognizable and outcomes ambiguous; these are typically social rather than physical world focussed. In such contexts, reasoning and judgement are highly valued and essential: simple answers that neatly fit the given situation are rarely prelearnable. Second, reasoning involves the three core elements of cognition, knowledge and metacognition. Third, judgement is referential rather than

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absolute. It occurs within knowledge cultures and paradigms as discussed in Chapter 1. Practitioners’ judgements are influenced by codes of conduct, norms, the knowledge-base of their professions and the knowledge and particular approach of the individual.

The Problem Space of the Global Health Care System With Its Discourse, Knowledge and Technology Many factors of the wider healthcare environment need to be taken into consideration in clinical reasoning. Healthcare professionals need to develop a broad understanding of the environment in which they work, including knowledge of the factors influencing health (e.g., the environment, socioeconomic conditions, cultural beliefs and human behaviour). In addition, they need to understand how the information age and the technological revolutions have affected healthcare demands, provision and expectation. They need to be able to work confidently and effectively with an increasing body of scientific, technical and professional knowledge. Developing a sound individual understanding of clinical reasoning and a capacity to reason effectively will facilitate the clinician's ability to manage complex and changing information.

Errors Avoiding errors in clinical reasoning requires attributes of skilled critical thinking including open-mindedness, consideration of other perspectives, awareness and critique of assumptions and more deliberate analysis as a backup of quick first-impression judgements often based on fixed clinical patterns and habitual practice. Rather than unquestionably accepting information, skilled critical thinking within clinical reasoning fosters a sort of healthy scepticism that appraises information for its accuracy, completeness and relevance to facilitate understanding and identification of solutions. Errors in the cognition of clinical reasoning (e.g.,

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information perception, interpretation, analysis) can be linked to the various forms of human bias evidenced in health- and non– health-related human judgement (Hogarth, 2005; Lehrer, 2009; Schwartz and Elstein, 2008). The priming influence of prior information (e.g., diagnosis provided in a referral, imaging findings, influence of a recent publication or course) and the tendency to attend to and collect data that confirm existing hypotheses (i.e., confirmation bias) are two classic examples. These errors are commonly associated with habits of thinking and practice that themselves are a potential risk for inaccurate pattern recognition. That is, in adopting a pattern recognition approach the novice or unreflective practitioner might focus too much on looking for the presence or absence of specific patterns and overlook other potentially important information or might find it difficult to see anything outside the most familiar patterns. Patterns can become rigid, making it difficult to recognize variations or alternatives. Within the changing face of health care and the trend towards more biopsychosocial practice that values qualitative information of the client's experience alongside quantitative biomedical measures, there is a need to look beyond the cognitive processes and cognitive errors of the clinician. Errors in psychosocial or ‘narrative’ focussed reasoning can be manifest as having no consideration of psychosocial factors or engaging in superficial assessment based on insufficient information. Questionnaires relating to psychosocial status can be helpful to quantitatively score a client's status on the construct(s) assessed, but they require complementary exploration through the client interview. That is, three clients may tick the same questionnaire box but for significantly different reasons. Practitioners who wish to adopt a client-centred approach or a team approach may make errors related to inauthentic implementation of espoused models of practice, lack of valuing or inclusion of the knowledge and reasoning input of team members or clients and limitations in interpersonal communication, including cultural incompetence. Errors can also be made in the realm of ethical reasoning, for example in the application of the principles of ethics to the client's individual circumstances (see Chapter 16) and with respect to shared decision making (see Section 3 chapters) and dilemmas in dealing with the client's wishes, informed position and power,

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which may be in conflict with what the practitioner considers to be in the client's best interests. Errors of reasoning can be reduced through greater understanding of clinical reasoning generally and greater understanding and critique of your own clinical reasoning. The risk for uncritical pattern recognition can be offset by strategies that minimize the assumptions frequently underpinning pattern recognition. Such error-avoidance strategies include screening to ensure information is not missed or inaccurate; qualifying clients’ meanings, consideration and, if justified, testing for competing hypotheses; and openly subjecting and comparing your reasoning to others’ reasoning.

Reflection Point 2 Can you identify any habits of practice in your own work? What strategies could you employ to ensure any habits you may have are sufficiently justified?

Clinical Reasoning Strategies In various chapters of this book, a number of interpretations of clinical reasoning are discussed from the perspectives of different disciplines, the history of clinical reasoning research and models of practice within which clinical reasoning occurs. In Table 3.1 we present an overview of key models, strategies and interpretations of clinical reasoning. These have been divided into two groups: cognitive and interactive models. TABLE 3.1

Models and Interpretations of Clinical Reasoning (CR) View CR as Cognitive Process

Model Hypotheticodeductive reasoning

Related Terms Procedural reasoning Diagnostic reasoning Inductionrelated

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Description The generation of hypotheses based on clinical data and knowledge and testing of these hypotheses through further inquiry. It is used

probabilistic reasoning

Pattern recognition

Pattern interpretation Inductive reasoning Categorization Mental representations

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by novices and in problematic situations by experts. Hypothesis generation and testing involve both inductive reasoning (moving from a set of specific observations to a generalization) to generate hypotheses and slower detailed deductive reasoning (moving from a generalization – if – to a conclusion – then – in relation to a specific case) to test hypotheses. Procedural reasoning identifying the client's functional problems and selecting procedures to manage them. Expert reasoning in nonproblematic situations resembles pattern recognition or direct automatic retrieval of information from a wellstructured knowledge base. New cases are categorized, that is, similarities are recognized (signs, symptoms, treatment options, outcomes, context) in relation to previously experienced clinical cases. Through the use of inductive reasoning, pattern recognition/interpretation is a process characterized by speed and efficiency, albeit with risk for error if relied on in the absence of adequate knowledge and experience. With increasing experience, clinicians move through three kinds

Forward reasoning; Backward reasoning Abductive reasoning

Inductive reasoning Deductive reasoning Inference to the best explanation

Knowledge reasoning

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of mental representations, from basic mechanisms of disease to illness scripts of clinical features and semantic qualifiers to exemplars derived from experience. Forward reasoning describes inductive reasoning in which data analysis results in hypothesis generation or diagnosis, utilizing a sound knowledge base. Backward reasoning is the reinterpretation of data or the acquisition of new clarifying data invoked to test a hypothesis. Forward reasoning is more likely to occur in familiar cases with experienced clinicians and backward reasoning with inexperienced clinicians or in atypical or difficult cases. Abductive reasoning, also called inference to the best explanation, refers to theorizing, typically regarding causal mechanisms, clinicians engage in when confronted with unexpected or unfamiliar information that cannot be deduced from established or accepted prior knowledge. It is an unproven, creative explanatory hypothesis for an area of clinical judgements when clear deductions are not available. Clinical reasoning involves the integration of knowledge,

integration

Intuitive reasoning

CR as Multidisciplinary Interactive reasoning Process

Conditional reasoning

Narrative reasoning

Interactive reasoning

reasoning and metacognition. Clinical reasoning requires domain-specific knowledge and an organized knowledge base. With experience, clinical reasoning and the associated knowledge drawn on may progress through stages culminating in both exemplars and memory of specific client instances. Instance scripts ‘Intuitive knowledge’ is Inductive related to ‘instance scripts’ or reasoning past experience with specific Heuristics cases that can be used Pattern unconsciously in inductive matching reasoning. Intuition may be associated with the use of advanced reasoning strategies or heuristics. Such heuristics include pattern matching and listing (or listing items relevant to the working plan). Interprofessional Members of a reasoning multidisciplinary team Team decision working together to make making clinical decisions for the client, about the client's condition, e.g., at case conferences, multidisciplinary clinics. Predictive Used by practitioners to reasoning estimate client responses to Projected treatment and likely reasoning outcomes of management and to help clients consider possibilities and reconstruct their lives after injury or the onset of disease. Reasoning associated with understanding the client's narrative (i.e., story) with respect to his or her pain, illness and/or disability experiences incorporating the client's personal perspectives on his or her experiences. Reasoning guiding the purposeful establishment and

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ongoing management of client-clinician rapport important to understanding the client's perspective and overall outcome. Collaborative Mutual decision The shared decision making reasoning making between client and clinician (and others) as a therapeutic alliance in the interpretation of examination findings, setting of goals and priorities and implementation and progression of treatment. Ethical reasoning Pragmatic reasoning Reasoning underpinning the recognition and resolution of moral, political and economic ethical dilemmas that impinge upon the patient's ability to make decisions concerning his or her health and upon the conduct of treatment and its desired goals. Teaching as Reasoning associated with the reasoning planning, execution and evaluation of individualized and context sensitive teaching, including education for conceptual understanding (e.g., diagnosis, disability, management options), education for physical performance (e.g., rehabilitative exercises) and education for behavioural change.

Examining the Range of Clinical Reasoning Strategies Many authors have written about different clinical reasoning strategies and processes. A summary of the most common ones that appear in the literature is presented in Table 3.1 based on the historical work of such researchers as Arocha et al. (1993); Barrows et al. (1978); Bordage and Lemieux (1991); Boshuizen and Schmidt (1992a, 1992b); Edwards et al. (1998); Elstein et al. (1978); Mattingly

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and Fleming (1994); Neufeld et al. (1981); Patel et al. (1988); and later publications such as Coulter (2005); Lipton (2004); and Loftus (2006). Examples of scholarly reviews with critique of existing models and implications for teaching include Banning (2007); Eva (2004); Kinchin and Cabot (2010); and Norman (2005).

Factors Influencing Choices About Clinical Reasoning Strategies Although clinical reasoning should be able to be justified in professional and public discourse, the choice of strategy cannot be prescribed beyond discipline-specific agreements regarding the breadth of scope and range of strategies appropriate. The strategies and processes described in Table 3.1 feature to some extent across most health professions represented in this book. Hypothetico-deductive reasoning (HDR) in the health professions traditionally refers to the process of formulating hypotheses based on specific features in the client's presentation and linked to established criteria (i.e., premises) for a type of clinical judgement (e.g., diagnosis). Formal ‘testing’ of initial hypotheses is said to occur through the collection of additional information such that when the judgement criteria are fulfilled the healthcare professional can deduce a specific hypothesis is confirmed or at least supported. Although diagnosis is perhaps the category of clinical judgement most researched and described in the literature, other categories of judgement where profession-specific criteria exist similarly use this process, for example clinical judgements regarding the need for caution in the examination and management, the need for referral for further medical consultation and judgements regarding prognosis (see Hypothesis Category framework Chapter 23). Pattern recognition occurs when features in the client's presentation are sufficiently familiar to the practitioner to enable recognition of a clinical pattern, and so further ‘testing’ through hypothetico-deductive reasoning is not essential. Pattern recognition is most commonly associated with diagnostic clinical judgements; however, pattern recognition is part of all human perception (Kahneman, 2011), and examples will be evident across all health professions’ areas of practice with differences perhaps

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more related to the extent they are relied on. Chapter 23 provides examples of different types of clinical patterns described in physiotherapy practice such as diagnostic and clinical syndromes. Narrative (or psychosocial) focussed reasoning some would argue exists as the opposite pole to diagnostic focussed reasoning with expert physiotherapists described as being able to dialectically move in their focus and reasoning between these two poles as unfolding client information requires (Edwards et al., 2004). Narrative reasoning sits in the ‘Interactive Process’ half of Table 3.1 as the process of coming to understand a client's narrative with respect to his or her pain, illness and/or disability experience. Incorporating the client's personal perspectives on his or her experiences is seen as a collaborative understanding reached between client and health professional rather than a biological impairment that can be reduced to objective measurement.

Selecting a Reasoning Approach Because HDR can be applied to any reasoning that formulates and tests hypotheses, it is likely to manifest in every health profession and with all client types. As a slower analytical process, it is often associated with the novice who lacks sufficient knowledge and experience to recognize clinical patterns and hence must consider and test a broader list of hypotheses not required by the ‘expert’. Experts may revert to HDR in complex or unfamiliar cases. Use of HDR will therefore depend on the experience and knowledge of the practitioner, his or her familiarity with the clinical presentation, the nature of the clinical judgements he or she is called to make (e.g., diagnostic versus narrative) and unfortunately perhaps also the time allocated per client. However, even with narrative reasoning, knowledge and experience enable identification of typical features of potentially restricting or facilitating psychosocial factors that elicit further investigation. Ultimately a hypothesis is still formed with perhaps the key difference being the validation of judgement is reached through client–practitioner consensus, not independent measurement. Each of the other reasoning strategies categorized as interactive processes in Table 3.1 is relevant to contemporary, holistic health care across all health professions. They would occur, implicitly or

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explicitly, with all healthcare professionals directly involved in client assessment and management to varying extent and ability depending on their personal philosophy of practice and responsibilities they assume. Knowledge reasoning integration relates to all reasoning strategies because all reasoning is informed by the health professions’ and individuals’ knowledge as shaped and organized by their ontology regarding what constitutes knowledge (fact or truth) and their combined research- and experience-based evidence. The role of intuitive reasoning in health professions’ practice continues to be contentious (Banning, 2007; Hogarth, 2005; Kinchin and Cabot, 2010) featuring more strongly in Nursing and Occupational Therapy research and practice descriptions (Banning, 2007; Fleming and Mattingly, 2008) than other health professions. The issue is not so much whether intuition exists. As Herbert Simon, best known for his seminal problem-solving research with chess masters, explains, intuition is ‘nothing more and nothing less than recognition’ (Simon, 1992, p. 155). Accurate intuitions of experts are best explained by the effects of prolonged practice. The question is, can the tacit knowledge and intuitive reasoning skilfully used by experts, but also a bias to those who rely on first impressions without further analysis (Kahneman, 2011), be made explicit for others to learn from with safeguards in place to minimize bias?

Professional Development of Clinical Reasoning Capability In pursuit of continuing professional development in relation to clinical reasoning, we could consider expertise in reasoning to be the ultimate goal. In a review of clinical reasoning literature in medicine, Norman (2005) suggested that there may not be a single representation of clinical reasoning expertise or a single correct way to solve a problem. He noted that ‘the more one studies the clinical expert, the more one marvels at the complex and multidimensional components of knowledge and skill that she or he brings to bear on the problem, and the amazing adaptability she must possess to achieve the goal of effective care’ (p. 426).

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Clinical reasoning and clinical practice expertise is a journey, an aspiration and a commitment to achieving the best practice that one can provide. Rather than being a point of arrival, complacency and lack of questioning by self or others, expertise requires both the capacity to recognize one's limitations and practice capabilities and the ability to pursue professional development in a spirit of selfcritique. And, it is – or at least we should expect it to be – not only a self-referenced level of capability or mode of practice; it is also a search for understanding of and realization of the standards and expectations set by the community being served and the profession and service organization being represented. In Fig. 3.1, such characteristics and expectations of experts are presented. We have added the idea of expectations to this discussion to emphasize that any human construct is sociohistorically situated. Beyond a research-driven science-based view of technical expertise, there is a need for any professional, but particularly experts, with his or her claim to superior service and performance, to address the needs of society. There is a growing expectation of client-centred humanization (including cultural competence, information sharing, collaborative decision making, virtuous practice) of expert practice that turns healthcare professional expertise into a collaborative professional relationship rather than an expert-empowered, technically superior, practitioner-centred approach. As highlighted in the research findings of Jensen et al. (2006), this client-centred approach is grounded in a strong moral commitment to beneficence or doing what is in the client's best interest. This manifests in therapists’ nonjudgemental attitude and strong emphasis on client education, with expert therapists being willing to serve as client advocate or moral agent in helping them be successful. Box 3.1 demonstrates an evolution in thinking about expertise, beginning with the classic research by Glaser and Chi (1988) of expert attributes. In 2000, we added to this view ideas of clientcentredness, collaboration, metacognition, mentoring, effective communication and cultural competence (Higgs and Jones, 2000). In 2008, we added the third group of characteristics for the third edition (Higgs and Jones, 2008). The fourth section added in this edition reflects messages in this book about the evolution of context and approaches to clinical reasoning.

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Box 3.1

Characteristics, Expectations and Emerging Abilities of Expert Practitioners a) General characteristics of experts (Glaser and Chi, 1988) ▪ Experts excel mainly in their own domains. ▪ Experts perceive large meaningful patterns in their domain. ▪ Experts are fast: they are faster than novices at performing the skills of their domain, and they quickly solve problems with little error. ▪ Experts have superior short-term and long-term memory. ▪ Experts see and represent a problem in their domain at a deeper (more principled) level than novices; novices tend to represent a problem at a superficial level. ▪ Experts spend a great deal of time analyzing a problem qualitatively. ▪ Experts have strong self-monitoring skills. b) Characteristics and expectations of health professional experts (Higgs and Jones, 2000) ▪ Experts need to pursue shared decision making between client and clinician if ‘success’ is to be realized from the client's perspective. ▪ Experts need to monitor and manage their cognitive processes (i.e., to use metacognition) to achieve highquality decision-making and practice action. ▪ Experts critically use propositional and experiencebased up-to-date practice knowledge to inform their practice. ▪ Expertise requires the informed use and recognition of patient-centred practice. ▪ Expert practitioners are mentors and critical companions (see Titchen, 2000) to less experienced practitioners. ▪ Experts are expected to communicate effectively with clients, colleagues and families and to justify clinical

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decisions articulately. ▪ Experts should demonstrate cultural competence. c) Further characteristics and expectations of expert professionals (Higgs and Jones, 2008) ▪ Experts demonstrate information and communication literacy. ▪ Experts value and utilize the expertise of other team members. ▪ Experts own and embody their practice model. ▪ Expertise goes beyond technical expertise in pursuit of emancipatory practice. ▪ Expert practice is community oriented. ▪ Expertise is informed by reflexive practice and research. ▪ Expert decision making is informed by the health and demographic trends in the communities they serve. ▪ Experts’ behaviour demonstrates a strong moral commitment to beneficence through such behaviours as patient advocacy and nonjudgemental attitudes. d) Emerging expectations of expert professionals ▪ Experts retain creativity and imagination. ▪ Experts appreciate the value of wisdom in practice. ▪ Experts look beyond their professional backgrounds for ideas and strategies. ▪ Experts look into innovative spaces for practice. ▪ Experts learn to balance economics and entrepreneurship with professional practice. ▪ Experts demonstrate epistemological and ontological fluency (see Chapter 2). ▪ Experts survive and flourish in the face of difficult problems and situations. We propose that clinical expertise, of which clinical reasoning is a critical component, be viewed as a continuum along multiple dimensions. These dimensions include clinical outcomes, personal attributes such as professional judgement, technical clinical skills, communication and interpersonal skills (to involve the client and others in decision making and to consider the client's perspectives), a sound knowledge base, an informed and chosen practice model

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and philosophy of practice, as well as cognitive and metacognitive proficiency. A related concept to expertise is professional artistry, which ‘reflects both high quality of professional practice and the qualities inherent in such artistic or flexible, person-centred, highly reflexive practice’ (Paterson and Higgs, 2001, p. 2). Professional artistry refers to ‘practical knowledge, skilful performance or knowing as doing’ (Fish, 1998, p. 87) that is developed through the acquisition of a deep and relevant knowledge base and extensive experience (Beeston and Higgs, 2001). Professional artistry reflects a uniquely individual view within a shared tradition involving a blend of practitioner qualities, practice skills and creative imagination processes (Higgs and Titchen, 2001). Paterson (2003) combined this idea with clinical reasoning to develop the concept and practice of professional practice judgement artistry (see Paterson and Higgs, 2008; Paterson et al., 2012). Similarly, ‘practice wisdom’ challenges our ideas of what it means to bring knowledge and wisdom, plus reasoning and judgement artistry, into the act of clinical decision making.

Chapter Summary In this chapter, we have portrayed clinical reasoning as a complex set of processes and interactions occurring within multiple and multidimensional problem spaces. The complexity of clinical reasoning in the health professions is evident in the scope of reasoning required to address the full range of biopsychosocial factors that can contribute to clients’ health problems and experiences. Adding to this complexity, healthcare professionals have at their disposal a broad range of clinical reasoning strategies to understand their clients and their clients’ health problems to assist their collaborative management. Although these reasoning processes have relevance to all areas of health professions’ practice, their use varies across professions (see Section 4 of this book). Greater understanding of the spaces in which clinical reasoning occurs and of the reasoning strategies that can be used will assist healthcare professionals’ understanding of their own clinical reasoning. Errors of reasoning are linked to different forms of human bias and can be reduced through greater understanding of

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clinical reasoning generally and greater understanding and critique of your own clinical reasoning. Professional development is an essential part of ensuring the quality of clinical reasoning and the capability of professionals performing this key practice.

Reflection Point 3 What clinical reasoning strategies can you identify in your own practice? How might you improve your clinical reasoning abilities?

References Arocha JF, Patel VL, Patel YC. Hypothesis generation and the coordination of theory and evidence in novice diagnostic reasoning. Med. Decis. Making. 1993;13:198–211. Banning M. A review of clinical decision making: models and current research. J. Clin. Nurs.2007;17:187–195. Barrows HS, Feightner JW, Neufield VR, et al. An analysis of the clinical methods of medical students and physicians. Report to the Province of Ontario Department of Health. McMaster University: Hamilton, ONT; 1978. Beeston S, Higgs J. Professional practice: artistry and connoisseurship. Higgs J, Titchen A. Practice Knowledge and Expertise in the Health Professions. Butterworth-Heinemann: Oxford, UK; 2001:108– 117. Bordage G, Lemieux M. Semantic structures and diagnostic thinking of experts and novices. Acad. Med.1991;66:S70–S72. Boshuizen HPA, Schmidt HG. Biomedical knowledge and clinical expertise. Cogn. Sci.1992;16:153–184. Boshuizen HPA, Schmidt HG. On the role of

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biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn. Sci.1992;16:153–184. Byrne C. Interdisciplinary education in undergraduate health sciences. Pedagogue (Perspectives on Health Sciences Education). 1999;3:1– 8. Checkland PB. Systems Thinking: Systems Practice. John Wiley & Sons: New York, NY; 1981. Coulter A. The Autonomous Patient: Ending Paternalism in Medical Care. The Nuffield Trust: London, UK; 2002. Coulter A. Shared decision-making: the debate continues. Health Expect.2005;8:95–96. Croker A, Higgs J. Reinterpreting professional relationships in healthcare: the question of collaboration. Croker A, Higgs J, Trede F. Collaborating in Healthcare: Reinterpreting Therapeutic Relationships. Sense: Rotterdam, The Netherlands; 2016:3–16. Duffy J. Stroke with dysarthria: evaluate and treat; garden variety or down the garden path. Semin. Speech Lang.1998;19:93–98. Edwards IC, Jones MA, Carr J, et al. Clinical reasoning in three different fields of physiotherapy: a qualitative study. Proceedings of the Fifth International Congress of the Australian Physiotherapy Association. 1998:298–300 [Melbourne, VIC]. Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys. Ther.2004;84:312–315. Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press: Cambridge, MA; 1978.

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Eva KW. What every teacher needs to know about clinical reasoning. Med. Educ.2004;39:98–106. Fish D. Appreciating Practice in the Caring Professions: Refocusing Professional Development and Practitioner Research. Butterworth-Heinemann: Oxford, UK; 1998. Fleming MH, Mattingly C. Action and narrative: two dynamics of clinical reasoning. Higgs J, Jones M, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:55– 64. Glaser R, Chi MTH. Overview. Chi MTH, Glaser R, Farr MJ. The Nature of Expertise. Lawrence Erlbaum: Hillsdale, NJ; 1988:xv–xxviii. Grace S, Higgs J, Horsfall D. Integrating mainstream and complementary and alternative medicine: investing in prevention. Proceedings of The University of Sydney From Cell to Society 5: Proceedings of the Health Research Conference, 9–10 November. The University of Sydney: Sydney, Australia; 2006:18–25. Higgs J. Physiotherapy, professionalism and selfdirected learning. J. Singapore Physiother. Assoc.1993;14:8–11. Higgs J, Jones M. Clinical Reasoning in the Health Professions. Higgs J, Jones M. Clinical Reasoning in the Health Professions. second ed. ButterworthHeinemann: Oxford, UK; 2000:3–14. Higgs J, Jones M. Clinical decision making and multiple problem spaces. Higgs J, Jones M, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:3–17. Higgs J, Titchen A. Towards professional artistry and creativity in practice. Higgs J, Titchen A. Professional Practice in Health, Education and the

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Creative Arts. Blackwell Science: Oxford, UK; 2001:273–290. Hogarth RM. Deciding analytically or trusting your intuition? The advantages and disadvantages of analytic and intuitive thought. Betsch T, Haberstroh S. The Routines of Decision Making. Lawrence Erlbaum Associates: Mahwah, NJ; 2005:67–82. Jensen GM, Gwyer J, Hack LM, et al. Expertise in Physical Therapy Practice. second ed. SaundersElsevier: St. Louis, MO; 2006. Jones M, Grimmer K, Edwards I, et al. Challenges in applying best evidence to physiotherapy. IJAHSP 4. 2006. Jones M, Grimmer K, Edwards I, et al. Challenges in applying best evidence to physiotherapy practice: part 2 —reasoning and practice challenges. IJAHSP 4. 2006. Kahneman D. Thinking, Fast and Slow. Allen Lane: London, UK; 2011. Kassirer JP, Kopelman RI. Learning Clinical Reasoning. Williams & Wilkins: Baltimore, MD; 1991. Kassirer J, Wong J, Kopelman R. Learning Clinical Reasoning. Wolters Kluwer, Lippincott Williams & Wilkins: Philadelphia, PA; 2010. Kennedy M. Inexact sciences: professional education and the development of expertise. Rev. Res. Educ.1987;14:133–168. Kinchin IM, Cabot LB. Reconsidering the dimensions of expertise: from linear stages towards dual processing. London Rev. Educ.2010;8:153–166. Lehrer J. How We Decide. Houghton Mifflin Harcourt: Boston, MA; 2009. Lipton P. Inference to the Best Explanation. second ed. Routledge: London, UK; 2004. Loftus S. Language in Clinical Reasoning: Learning and

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Using the Language of Collective Clinical Decision Making. Doctoral thesis. University of Sydney: Sydney, NSW; 2006 [Available from] http://ses.library.usyd.edu.au/handle/2123/1165 [viewed 20 February 2017]. Loftus S, Higgs J. Clinical decision-making in multidisciplinary clinics. Flor H, Kalso E, Dostrovsky JO. Proceedings of the 11th World Congress on Pain: International Association for the Study of Pain. IASP Press: Seattle, WA; 2006:755– 760. Mattingly C, Fleming MH. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. FA Davis: Philadelphia, PA; 1994. Neufeld VR, Norman GR, Barrows HS, et al. Clinical problem-solving by medical students: a longitudinal and cross-sectional analysis. Med. Educ.1981;15:315–322. Norman G. Research in clinical reasoning: past history and current trends. Med. Educ.2005;39:418– 427. Patel VL, Evans DA, Groen GJ. Biomedical knowledge and clinical reasoning. Evans DA, Patel VL. Cognitive Science in Medicine: Biomedical Modeling. MIT Press: Cambridge, MA; 1988:49–108. Paterson ML. Professional Practice Judgement Artistry in Occupational Therapy, Doctoral Thesis. University of Sydney: Sydney, NSW; 2003. Paterson M, Higgs J. Professional Practice Judgement Artistry. CPEA Occasional Paper 3. The Centre for Professional Education Advancement. University of Sydney: Sydney, NSW; 2001. Paterson M, Higgs J. Professional practice judgement artistry. Higgs J, Jones M, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed.

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Elsevier: Edinburgh; 2008:181–189. Paterson M, Higgs J, Donnelly C. Artistry and expertise. Robertson L. Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley-Blackwell: Oxford, UK; 2012:93–106. Payton OD, Nelson CE, Ozer MN. Patient Participation in Program Planning: A Manual for Therapists. FA Davis: Philadelphia, PA; 1990. Reilly S, Douglas J, Oates J. Evidence-Based Practice in Speech Pathology. Whurr: London, UK; 2004. Round AP. Introduction to clinical reasoning. J. Eval. Clin. Pract.2001;7:109–117. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: theory and implications. Acad. Med.1990;65:611–621. Schwartz A, Elstein AS. Clinical reasoning in medicine. Higgs J, Jones M, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:223–234. Simon H. What is an ‘explanation’ of behavior?. Psychol. Sci.1992;3:150–161. Titchen A. Professional Craft Knowledge in Patient Centred Nursing and the Facilitation of its Development. Ashdale Press: Oxford, UK; 2000.

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4

Clinical Reasoning and Models of Practice Joy Higgs, Franziska Trede

CHAPTER AIMS The aims of this chapter are to: ■ reflect on factors influencing practice approaches in general and clinical reasoning in particular, ■ critically present different models for practice, ■ support a Critical Social Science Model as a basis for practice and ■ encourage practitioners to critically develop their own practice models.

KEY WORDS Practice models Clinical reasoning

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Critical social science

Introduction Healthcare practice operates in increasingly more complex, diverse and uncertain environments. Patients and clients of health care are better informed, technology is advancing, and healthcare practice is constantly changing. It is important in this context to adopt an informed and critical stance to practice. Being aware of the interests that drive and frame practice and practice models and understanding the way these models influence practice actions and clinical reasoning are necessary aspects for practitioners to be responsible and critically competent in demanding work environments. In this chapter, we examine different practice models and propose advantages in relevant contexts of adopting a critical practice model. The importance of critique in today's challenging and dynamic healthcare environments is linked to practitioners reclaiming their human agency and critical reflection capacity in practice models that underpin practice reasoning, action and reflexive review.

Recognizing Our Practice Context and Influences Neither clinical reasoning nor professional practice, as a whole, occurs in a vacuum. We can think of acts of health care, client– practitioner(s) interactions and the progress of clients towards wellbeing as occurring in layered contexts of practice. These layers include (from the inside out) the immediate situation and needs of clients, the particular goals and interests of the practitioners working with clients to facilitate their well-being, the roles and inputs of clients' families and carers, the influences and inputs of the local healthcare setting, the wider influences of the communities of professional practice that set standards and norms of practice and the wider systems of institutional, healthcare system requirements and resources and the national and global healthcare arenas. All of these influences affect the nature of healthcare choices made by and centred on clients as part of collaborative clinical

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decision making and their health outcomes. In this chapter, we explore the place of models of practice created and enacted by practitioners, professions and healthcare teams as they work across these layered contexts of practice (Fig. 4.1).

FIG. 4.1 Influences (local and global) in healthcare

interactions.

Reflection Point 1 We invite you to think about the outer circle of Fig. 4.1 and take seriously our opening statement that Neither clinical reasoning nor professional practice, as a whole, occurs in a vacuum. What are the world's biggest health problems and recent policies of the World Health Organization that national healthcare systems and healthcare professions are engaging with? Can you list a few of the global agendas? We often lose the connection between the global, national and local picture, and it is seductive to reduce health models to the biomedical level. Starting to think about the big picture first influences practice models and clinical reasoning processes at the micro level. What connections exist between how these global influences, society expectations, advances in technology and research knowledge influence your central

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interaction with patients and colleagues?

Understanding and Valuing Interests and Priorities Clinical reasoning is a challenging undertaking. It is influenced by a complex interplay between different interests and priorities that can range from wanting to assert professional authority and control over healthcare situations, to wanting to negotiate common ground with clients and create meaning, to striving to learn, transform and change oneself and one's clients. This discussion is framed by Habermas' (1972) theory of cognitive interests, in which he argued that ideas shape our interests and actions. Here we explore the link between interests and the actions of clinical reasoning and clinical practice. Interests can be thought of as the motivation for wanting to think and act in certain ways. Such motivation can be internally driven by values, attitudes and desires, such as a humanistic perspective, valuing of rationality or wanting to be patient-centred. Interests can also be shaped by external interests, such as pressures to adhere to the dominant healthcare practice model, system imperatives such as economic rationalism, society and peer expectations of professional behaviour and trends and discourse in health care. Healthcare professionals are accountable and accept responsibility for their decisions and actions. What values, assumptions and reasons underpin and guide their thinking and decisions? Often such interests are subconscious and have been acquired through the pervasive and often osmotic process of professional socialization (Eraut, 1994) rather than being consciously learned and adopted through critical self-appraisal and informed choice of a desired model of practice. Once practitioners are aware of their interests and understand what motivates these interests, they are in a better position to make critically conscious choices as to how they seek to frame their clinical reasoning and consequent actions.

The Social and Historical Construction of Practice Approaches 143

Professional practice is socially and historically constructed (Higgs, 2016, p. 191): “it comprises individual and shared activities and expectations across a community of practice; it is manifest in language, discourses and traditions; its conduct is linked to morality and ethical conduct; its standards and implementation are regulated and evaluated by individual practitioners as well as the practice community, external authorities and society; it is manifest in a range of levels of expertise development; and beyond all of this, practice is embodied through practical consciousness”. Deliberate professionals need this understanding of practice as they knowingly create their practice models and take ownership of their clinical reasoning, decision making and, ultimately, the outcomes of their practice actions.

The Shaping of Practice Models: The Place of Ideology We tend to interpret and justify our clinical reasoning processes with theoretical knowledge and research findings without acknowledging the interests and assumptions that inform our practice. Practice is justified with theories, guidelines and professional training. The ideology behind these theories and training remains hidden. To bring the assumptions out of hiding and question our way of reasoning enhances our practice awareness and provides us with real choices about practicing optimally in each given clinical context. It would be simplistic and limiting for a profession to define its practice purely on the basis of technical knowledge and skills (Schön, 1987). This would reduce practice to the aspects that can be measured with empirico-analytical evidence only. What we observe and what we do must be interpreted to make sense for us and to be communicated to others. Measurements and numbers on their own are meaningless. As professions develop and mature, they become more involved with questions of expertise development and knowledge growth. Higgs et al. (1999) claimed that a mature profession is one that enters into dialogue about its practices, is selfreflective and proactively transforms with global changes. Professional ideology and interests, whether consciously or unconsciously enacted, inform practice models and professional

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practice (Newman, 1994). Professional ideology is made up of the values, assumptions and prejudgements that guide our thinking (Therborn, 1999). The type of practice we aspire to enact, the type of knowledge and evidence we value and utilize in practice, the way we justify our way of practicing and our clinical reasoning are all informed by interests that guide our curiosity in the first place.

Workplace Influences Trede's (2006) research on clinical practice approaches identified the importance and effect of external context factors on the preferred or existing practice model of the practitioners and the workplace. She found that the level of acceptability of the technical biomedical model was high in situations where the environment was ‘hi-tech’, and healthcare delivery relied on advanced technology and in acute care or emergency situations where patients were very ill or required critical care. In such arenas, there was an unchallenged focus on pathological diagnoses and biomedical intervention approaches, with the expectation of patient compliance. In less acute and less technology-dependent healthcare settings, participants in Trede's research considered that there was greater opportunity for patient-centred care that involved patient participation in clinical decision making. The notion of emancipatory practice was foreign to most of the participants, and in early discussions they considered that in their workplace situations, with high workloads, time pressures, medical model frameworks, traditional approaches to professional hierarchies and an emphasis on evidence-based practice and cost efficiency, that moves to treat patients on an equal footing in terms of clinical decision making were not particularly feasible, expected or needed.

Working Across and Within Different Practice Communities Work by Croker (2011) into collaboration between healthcare professionals and in teams identified the importance of understanding how different communities of practice influence workplace expectations of how professionals work and of how they work together. Her research explored the ways practitioners often

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work across multiple practice communities including their direct work teams, their disciplines and their workplaces. Not only do they need to respond to the norms, expectations and practices of each community, but they may well be faced with challenges associated to each of these communities having different, and possibly contradictory, practice models. A practitioner could work in both a patient-centred palliative care unit and a protocol-driven cardiac surgery biomedical-model ward yet desire to be a client collaborator who helps clients conduct their own wellness narratives, in rejection of the restitution narrative (Alder, 2003). In her research into practice models, Trede (2006) identified that practitioners unknowingly adopted their practice models. Much of their practice was unreflective and taken for granted. Most of these practitioners, as physiotherapists, identified a preference for the biomedical practice model, as the hegemonic system and educational model of the participants' workplaces and professional socialization. Most of these research participants claimed to be patient-centred but generally reverted therapist-centred approaches based on technical interests. For a minority, the practice model preferred by the practitioner was so incompatible with the workplace model that the practitioner chose to leave that workplace.

Being Deliberate: Making Choices About Our Practice Models Another key influence on our chosen practice model is how we consciously position and act in the world. As Arendt (1996) reminds us, practice or action is no neutral activity, and if we do not understand the wider influences on us and choose how to position ourselves, reason and be in practice, then others will choose it for us. Trede and McEwen (2016a, p. 7) introduced the term deliberate professional to ‘define ways of developing moral, thoughtful, purposeful and agentic stances that enable practitioners to counterbalance one-dimensional and instrumental practices’. Deliberate professionals are people who are informed by moral consideration of self and others; they have the capacity and drive to promote positive changes through their professional practice. ‘The deliberate professional is aware of complex and ever-changing

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relational dimensions in practice that shape the way practitioners think, talk and relate to self, others and the wider context around them; behave thoughtfully and courageously; resist unreflected conformity and notions of neutrality, repair and change conditions; and not disavow accepted practices, but rather acknowledge, appreciate, critique and change aspects of practices that need improving’ (Trede & McEwen 2016b, p. 22). Because, by definition, our practices are pursued deliberately, knowingly and informedly, practitioners need to realize and enact their practices within a coherent and deliberately owned practice model (Higgs, 2016).

Reflection Point 2 When we consider the global, national and local interests on how practice should be done, it could be assumed that practice models and clinical reasoning processes are predetermined and prescribed. Could you argue that your way of practicing and reasoning is informed by the ideas of the deliberate professional as outlined earlier?

Models of Practice Clinical reasoning occurs within models of practice. These models can be tacit (understood and largely unquestioned), controversial (known and debated), hegemonic (dominant and widely supported) and chosen (knowingly adopted). Practice models occur at different levels: they identify the broad strategy (such as the biomedical model) that operates at the level of a system, organization or workplace; they frame the interactions of team members (such as patient-centred care); and they give meaning and direction to the actions of individual practitioners (such as an evidence-based or humanistic orientation). In each case, they reflect or challenge the interests (benefits and motivations) of the people working within the systems in which these models operate. Models of practice are abstract ideas of what practice should look like if it followed a given framework. These frameworks comprise a variety of interests, criteria, norms, practice principles and strategies and behavioural expectations that inform clinical

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reasoning and practice. Models can be thought of as mental maps that assist practitioners to understand their practice. They serve to structure and to fine-tune practitioners' clinical reasoning. Whether they are learned, chosen or unconsciously acquired through professional socialization, practice models generate the principles that guide practice and create the standards practitioners strive towards and the behavioural expectations that determine performance. Professional practice models can be categorized in a number of ways. One such categorization is based on the theory of knowledge and human interest (Habermas, 1972). According to this theory, there are three types of interest: technical, practical and critical, each of which generates a certain type of knowledge. Each interest directs the types of question that can be asked in practice, in turn dictating the type of knowledge that is generated and used in practice and the way we practice. These interests not only shape the professional practice we enact and determine which modes of practice we see as valuable, but they also influence the identity we adopt as professionals, how we see the role of patients, how we believe clinical decisions should be made and how we justify and argue our professional roles and actions. Table 4.1 presents the illness, wellness and capacity practice models and their inherent interests, based on the three Habermasian interests. We argue that practice and reasoning require critical thinking that is based on critical interests; critical thinking based on technical and practical interests is important but incomplete in meeting the challenging demands of current practice. TABLE 4.1

Three Frameworks for Professional Practice Models in Health Practice Model Kind of interest Approach Philosophical paradigm Health

Illness Model

Wellness Model

Capacity Model

Technical

Practical

Emancipatory

Clinician-centred Patient-centred EmpiricoInterpretive analytical Reductionist Holistic

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Patient-empowered Critical Holistic

definition Focus of health Clinician has power Patient power Practice knowledge Stance towards status quo Role of patient

Role of clinician Context of decision making Clinician as helper Clinicians helping patients Clinician selfawareness

Technical

Practical

Political

Clinician has power Disempowered

Clinician may share some power Empowered

Equal power sharing

Out of context

Psychocultural context Historical-political (definitely not context political) Helping to cope Helping to liberate

Empowered in a way that can be sustained PropositionalPropositional-technical Propositional-technical, technical and experiential experiential and political Taking things for Being aware of taken- Challenging status quo granted, for-granted things and changing accepting, frameworks reinforcing Passive, Interactive, Interactive, participative, obedient, not participative but contributing, selfasked to think obedient, encouraged determining, learn to for self to think a bit for self think for self Teacher/provider Listener Facilitator

Helping to survive To comply

Unreflective

To cope

To liberate

Reflective with the aim Reflective with the aim to empower to transform

Table 4.1 illustrates how interests shape practice models, knowledge and clinical reasoning in practice. Some aspects are of particular relevance in this discussion of clinical reasoning.

■ The focus and definition of health selected influence healthcare goals pursued. When healthcare focuses on illness and biomedical pathology, the goal of care is limited to reducing deficit or merely helping patients cope with current situations. When health is seen as a potential, the focus of reasoning and health care is on building capacity. A capacity practice model 149

transcends the dualism of the illness and wellness models. ■ The relative power of the clinician and patient varies significantly across different practice models and is reflected in clinical reasoning strategies. For instance, in an emancipatory model collaboration, inclusiveness and reciprocal facilitation of responsibility are embedded in clinical decision making. ■ The type(s) of knowledge that practitioners value is grounded in their professional socialization. Practice knowledge is inclusive of dominant scientific (empirico-analytical) and psycho-sociocultural (ethnographic, phenomenological) constructs of knowledge. ■ The relative roles of practitioners and patients are significantly influenced by practice approaches, whether chosen or unconsciously adopted. Biomedical practice models speak of providers and recipients of practice. In an emancipatory/capacity model, patients and practitioners engage in dialogues and learn from each other, both accepting the roles of listening and negotiating. ■ The level of critique and reflexivity that practitioners bring to their practice is grounded in practice and reasoning approaches. Critical selfawareness of professional or personal interests is the key to consciously choosing a practice model. Traditionally in orthodox Western medicine, most practitioners acquire a biomedical science or medical practice model during their

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education and practice acculturation. This acquisition frequently occurs with limited critique or questioning of this model. Such practitioners are commonly unaware of their practice model because it represents the unquestioned norm, and they are consequently unaware of how this model influences the way they reason. They reason within their adopted practice model without challenging the values and interests their practice model may entail. The key features of this model and reasoning are an emphasis on cure and the restitution of health, the role of the practitioner as professional authority in the decision-making process, and the patient being regarded as ‘the one without expertise’. At times practitioners even disregard the patient's knowledge of self and his or her ability to participate in health care apart from being compliant and seeking cures. Reasoning in this model is largely performed by the expert/practitioner and is hypothetico-deductive in nature following the hypothesis generation and testing strategy of the hegemonic scientific model.

Reflection Point 3 The illness, wellness and capacity models outlined earlier are theoretical constructs that do not exist in their purity in practice realities. However, what do you think are the benefits of this framework of conceptualizing professional practice models in health? How could you work with this framework in your teaching or clinical practice?

Reasoning in a Critical Social Science Model for Practice To consider how a practitioner's chosen and enacted model of practice influences his or her clinical reasoning, we now turn to an in-depth interpretation of a particular model – the Critical Social Science (CSS) Model – as researched by Trede (2006). The primary goal of the research (see Trede, 2006; Trede and Higgs, 2003) was to understand how a CSS perspective, with its inherent emancipatory interests, might influence and transform healthcare practice. The

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development of the CSS model for practice resulted from four cycles of critical transformative dialogues based on critique and reflexivity and the pursuit of change that led to liberation. The dialogues involved two-way conversations with self and others (including other participants, patients, colleagues) using critical reasoning. The first dialogue described the status quo of the CSS and health-related literature and developed a conceptual approximation of a CSS model for healthcare practice. The second dialogue involved critique and interpretation of the related physiotherapy literature followed by a critical dialogue with the first group of physiotherapist participants to critique the status quo of physiotherapy practice. In the third dialogue, a group of practitioners trialled a CSS approach using action-learning strategies. The fourth dialogue, with another physiotherapy participant group, envisioned a CSS approach to practice. In discussion of the status quo of practice, a few participants in Trede's study, either through dissatisfaction with their model or prompted by further education, consciously chose to adopt an alternative model based in humanistic philosophy or, less frequently, a CSS perspective. The more conscious the choice of practice model and the more this model differed from hegemonic practices, the more likely it was that the practitioners adopted a heightened level of awareness into their reasoning and behaviour. Instead of reasoning against scientific knowledge, evidence, established practice guidelines or learned behaviour expectations set by their professions, workplaces or society at large, these practitioners sought to critically construct their own set of practice standards and ways of being in the world of practice, and they monitored their behaviour against these standards. These participants, without theoretical understanding of CSS theory, had created a critical practice model. A critical practice model starts with the assumptions that practice is complex, outcomes are uncertain and perceptions and interpretations of patient presentations are diverse. This means that a patient with an arthritic knee is not simply ‘an arthritic knee’ – an object of treatment. Instead, practitioners need to consider patients wholistically; this includes age, gender, attitude towards pain and physical activity and expectations of practitioners and themselves. Gaining a critical perspective means becoming aware of the

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interests that collide in practice and questioning these interests. Critical social science is distinguished from the natural and social sciences in that it focuses on critique that leads to change and emancipation (Fay, 1987). Critique is raising awareness about interests that have arisen in the sociocultural historical worlds that influence clinical reasoning and practice approaches. From a CSS perspective, critical thinking means being able to take a sceptical stance towards self, culture, norms, practices and institutions and policy and regulations. Critical thinking questions the very roots of discipline-accepted knowledge and how it informs clinical reasoning (Brookfield, 2012; Trede and McEwen, 2015). During clinical reasoning, this scepticism is both a conscious and a metaprocess; the practitioner would explicitly challenge data, decisions and treatment alternatives and bring a heightened awareness of his or her own thinking and actions into the moments of practice, not just to posttreatment reflections. CSS starts from the assumption that the influences listed earlier are human-made and therefore can be changed. Before these aspects of practice and reasoning are accepted and adopted, they should be challenged and checked for their intentions and assumptions. CSS separates truth from ideology, reason from power and emancipation from oppression. The agenda of CSS is to critique, engage in dialogue and transform the status quo at an individual and a collective level, working towards transformation through professional development and maturity to become a selfaware and articulate professional who works with patients, policy and institutions that respect diversity and support social justice. The focus is on transforming unnecessarily constraining policies and oppressive practices that restrict workforce development and patient empowerment.

Reflection Point 4 The CSS model may appear to advocate thinking against the grain at all costs because it has critique and scepticism about current ways of thinking and practicing at its core. The purpose of a CSS perspective is not criticism and identifying deficits but rather to inclusively understand current practices with their economic,

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political and cultural influences to identify the way forward to strengthen what is already working well and to change what needs to be improved. What are the economic, political and cultural influences that need to be improved in your clinical environment? During Trede's (2006) research, some of the participants trialled and experienced what it was like to transform their practice into (or towards) a critical practice model. This dialogue cycle included a preimplementation workshop, an action-learning phase and a critical appraisal workshop. Participants were informed about the findings from the first phase of the research investigating the status quo of physiotherapy practice models. They were educated about the dimensions of critique, power and emancipation of CSS, and they were invited to critically discuss our critique of current practices. The findings from this phase indicated that the practitioners had varied levels of readiness (cognitive, emotional and pragmatic) to engage in practice reflection and change and different perceptions of the value of CSS as a basis for practice. Different levels of engagement with CSS were identified. Some of the participants were happy to help with the research but persisted with their more traditional biomedical model approaches. Others practiced a patient-centred model closely related to the emerging CSS model.

The CSS Model The CSS model (Trede, 2006) for practice has two core dimensions.

An Emancipatory Dimension The emancipatory dimension entails recognition that to adopt a CSS or emancipatory model in a world of practice where such practice is a minority view requires a journey of critical transformative dialogues of emancipation for the practitioner. The research identified five modes of engagement with CSS as a practice model. These were labelled: 1. The Uninformed those who had not heard of CSS 2. The Unconvinced those who trialled CSS but did not change their current practice, which remained in the biomedical

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model 3. The Contemplators those who trialled CSS and thought that some aspects of CSS were convincing but encountered too many perceived barriers to transform their practice substantially 4. The Transformers those who were convinced of CSS and were transforming aspects of their practice 5. The Champions those who were convinced of the value of CSS and embodied CSS in their practice Across these five levels, the participants progressively engaged more deeply in transforming their practice towards a CSS approach, learning more about CSS, came to value these principles and practices more deeply, and journeyed further away from their traditional practice knowledge base and practices. Table 4.2 details the interests, practices and characteristics of each of these modes. Of particular relevance here are the changing patterns of interaction, power use and reasoning approaches, ranging from therapistcentred and therapist-empowered decision making for patients to patient-centred and mutually empowered decision-making dialogues with patients. TABLE 4.2 Practice Dimension Definition

The Uninformed

The Unconvinced The Contemplators

Those who have not heard of CSS

Those who have trialled CSS but do not change their current practice

Those who have explored CSS in their practice and have chosen to adopt some aspects of CSS in their practice

Practice model

Typically the Typically the Mixed biomedical and critical biomedical model biomedical model model

Interests

Technical/practical Technical/practical Practical/technical/emancipatory

Self-appraisal

Mastering technical application

Mastering technical application

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Mastering technical application and acknowledging patients' interests

Mode of critique

Critiquing practice from an empiricoanalytical, technical perspective

Critiquing practice from an empiricoanalytical, technical perspective

Critiquing practice from practical perspectives working within systems that are taken for granted or at least assumed unchangeable

Approach to reasoning

Linear, cause and effect, minimal contextual consideration Propositionaltechnical

Linear, cause and effect, minimal contextual consideration Propositionaltechnical

Appreciate critical reasoning without adopting it

Therapist is the expert and dominates

Therapist is the expert and dominates

Therapist is the expert but acknowledges patient experience

Owned by physiotherapist's propositional knowledge

Owned by propositional knowledge and some nonpropositional knowledge

Approach to knowledge

Patient relationships

Power/authority Owned by physiotherapist's propositional knowledge

Propositional-technical and experiential

Context interpretation

Within biomedical Within biomedical Within biopsychosocial domain domain domain

Professional identity and role

Technical and telling patients what they need

Technical and telling patients what they need

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Technical, practical and empathic, guiding patients

Goals

Achievement of positive technical, biomedical outcomes

Achievement of Achievement of functional and positive technical, practical outcomes biomedical outcomes

Five Prototypical Engagements With CSS (Trede, 2006).

Reflection Point 5 The prototypical categorization of how professionals engage with the CSS model is intended to help readers identify themselves where they fit and where they might possibly want to position themselves on the table. It can be used as a discussion starter in teams to clarify purposes of clinical reasoning processes.

A Critical, Lived Dimension In advocating consideration and adoption of a CSS practice model, we recognize that critical practice has variable relevance and potential across the range of practice contexts and that other models (as discussed earlier) may be preferable or more feasible in certain contexts. Critical physiotherapy practice is the practice model of choice in situations of emancipatory need, predilection and support. The ultimate value of critical practice is its capacity to enhance the quality of life of its protagonists through critical appraisal, particularization, empowerment and constructive collaboration in shared vision and actions. CSS practice is an accessible and acceptable choice when four situations coincide: a) when there is a perceived need for patients and physiotherapists to collaborate in clinical decision making and to liberate practice; b) when it is the preferred practice model of a practitioner (or group) who is a champion of critical practice; c) when other team members are supportive of this approach and keen to embody authentic critical practice; and d) where

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management and organizational systems support rather than restrict critical approaches. These four situations create a facilitative and supportive environment for embedding a critical practice perspective in the existing discourse. Critical practice would then be the practice model of choice because marginalized voices of patients and practitioners are heard and acted upon in a systembased environment that is sensitive, supportive and responsive to critique and emancipation. Practitioners bring their assumptions, values and prejudgements and professional experiences to the clinical situation. Practitioners with a critical perspective are aware of the interests that collide in practice, and they question these interests. Practicing in a CSS model involves engaging in critical transformative dialogues that enable practitioners to make practice model choices and living CSS in the every day. Practicing and reasoning within a CSS model require practitioners to:

■ challenge models of practice, practice cultures and taken-for-granted practice interests, ■ choose CSS as the overall practice framework for decision making and action, ■ be accountable to self and to those influenced by their professional practice, ■ analyze what practice knowledge is valuable and situationally applicable, ■ critically and responsibly exercise choice about courses of action, ■ negotiate a practice approach with patients/clients, ■ engage patients (and carers) in transformative dialogue, ■ plan a team CSS approach, ■ imagine alternatives, ■ be willing to question their sense of self, their 158

professional identity and their chosen model of practice, ■ critically appraise their reasoning and practice on a big-picture level (is my practice model relevant and meaningful?) and within the moments of reasoning and practice and ■ adopt a critical pedagogy approach to teaching and learning. Such an approach involves and enhances learners' capacity to question existing assumptions and current practices. The relevance of CSS for healthcare professional practice is that such a practice model:

■ builds the capacity of practitioners for critical self-reflection as a tool for practice development, ■ democratizes professional relations and ensures inclusive, appropriate and ethical practice that empowers patients, ■ raises awareness of interests and values that inform clinical reasoning, ■ redefines professional identity within a constantly changing world to empower practitioners and liberate them from restrictive hegemonic practice rules and ■ encourages rethinking of the boundaries and inclusions of the practice context. A critical practice model is challenging because practitioners must constantly question their clinical reasoning and maintain a critical stance to current practices. This critical stance to self and others can only be sustained within a supportive environment that facilitates such emancipatory learning. Adopting a CSS perspective

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requires advanced clinical reasoning skills that allow critical reflection about self, patients and the wider practice context and open, yet sceptical, professional relationships with patients.

Chapter Summary In this chapter we have presented:

■ practice models and their importance, ■ the interdependence between reasoning and practice in the context of models of practice and ■ the implication of a critical social science practice model for practice and reasoning. Reflection Point 6 In current times of rapid and relentless change, the CSS model can shape clinical reasoning processes to help students and practitioners steer through uncertainty and complexity. There is an urgent need to educate deliberate professionals with criticalthinking skills that opens up new possibilities of practicing. Where in your teaching do you explicitly discuss different professional models of health? How do you cultivate critical-thinking approaches that encourage students to think for self and imagine how to practice otherwise? How could you assess students' capabilities to engage with the CSS model and become deliberate professionals?

References Alder S. Beyond the restitution narrative. [PhD thesis. University of Western Sydney, Sydney, Australia, viewed 1 June 2017; Available from] http://handle.uws.edu.au:8081/1959.7/22873; 2003. Arendt H. Ich will verstehen: Selbstauskünfte zu leben und werk. Piper: Ursula Ludz. München; 1996.

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Brookfield S. Teaching for Critical Thinking: Tools and Techniques to Help Students Question Their Assumptions. Jossey-Bass: San Francisco, CA; 2012. Croker A. Collaboration in Rehabilitation Teams. [PhD thesis. Charles Sturt University, Australia] 2011. Eraut M. Developing Professional Knowledge and Competence. The Falmer Press: London, UK; 1994. Fay B. Critical Social Science. Cornell University Press: Ithaca; 1987. Habermas J. Knowledge and human interest. [trans. JJ Shapiro. Heinemann, London, UK] 1972. Higgs J. Deliberately owning my practice model: realising my professional practice. Trede F, McEwen C. Educating the Deliberate Professional: Preparing Practitioners for Emergent Futures. Springer: Dordrecht, The Netherlands; 2016:189– 203. Higgs J, Hunt A, Higgs C, et al. Physiotherapy education in the changing international healthcare and educational contexts. Adv. Physiother.1999;1:17–26. Newman M. Defining the Enemy: Adult Education in Social Action. Stewart Victor Publishing: Sydney, Australia; 1994. Schön DA. Educating the Reflective Practitioner. JosseyBass: San Francisco, CA; 1987. Therborn G. The ideology of power and the power of ideology. Verso: London, UK; 1999. Trede F, Higgs J. Re-framing the clinician's role in collaborative clinical decision making: re-thinking practice knowledge and the notion of clinician– patient relationships. Learning in Health and Social Care. 2003;2:66–73. Trede F, McEwen C. Critical thinking for future practice. Davies M, Barnett R. Palgrave Handbook of

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Critical Thinking in Higher Education. Palgrave Publishers: New York, NY; 2015:457–475. Trede F, McEwen C. Scoping the deliberate professional. Trede F, McEwen C. Educating the Deliberate Professional: Preparing Practitioners for Emergent Futures. Springer: Dordrecht, The Netherlands; 2016:3–14. Trede F, McEwen C. Carving out the territory for educating the deliberate professional. Trede F, McEwen C. Educating the Deliberate Professional: Preparing Practitioners For Emergent Futures. Springer: Dordrecht, The Netherlands; 2016:15–28. Trede FV. A critical practice for physiotherapy. [PhD thesis. University of Sydney, Sydney, Australia] 2006.

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5

The Development of Clinical Reasoning Expertise Henny P.A. Boshuizen, Henk G. Schmidt

CHAPTER AIMS The aims of this chapter are to: ▪ examine the development of clinical reasoning expertise, particularly in medicine, ▪ answer the question of whether clinical reasoning can be taught to medical students and ▪ present approaches to clinical reasoning skills training building on the stage theory.

KEY WORDS Clinical expertise Stage theory

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Knowledge structures

Introduction The main objective of medical schools is to turn relative novices into knowledgeable and skilled professionals who are able to solve clinical problems and are aware of the reach of their knowledge and skills and what goes beyond their capacities. In this chapter, we seek to answer the question of whether clinical reasoning can be taught to medical students. We start by describing the development from novice in medicine to expert, providing a theoretical cognitive psychological framework. Several approaches to clinical reasoning skills training are then described, and the implications of this theory are considered for the way medical education can improve students' clinical reasoning.

A Theory of the Development of Medical Expertise For a long time, it has been thought that the human mind can be trained in logical thinking, problem solving or creativity and that these skills could transfer to all domains of daily and professional life. For this purpose, children are encouraged to play chess or to learn Latin in school. Polya's (1957) problem-solving training program also cherishes this general idea about the human mind. In the same vein, it was thought that experts in an arbitrary domain had trained their minds and had developed general problemsolving and thinking skills. This opinion has, however, been superseded, because research outcomes have shown that experts in a specific domain have not developed problem-solving skills that can be applied across domains. Instead, domain knowledge and the associated skills to use this knowledge in problem solving develop simultaneously and interdependently. In medicine, research has shown that clinical reasoning is not a separate skill acquired independently of medical knowledge and other diagnostic skills. Instead, research suggests a stage theory of the development of medical expertise, in which knowledge acquisition and clinical reasoning go hand in hand (Boshuizen and

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Schmidt, 1992; Schmidt and Boshuizen, 1992; Schmidt et al., 1992; Schmidt et al., 1990). This theory of medical diagnosis is essentially a theory of the acquisition and development of knowledge structures upon which a student or a physician operates when diagnosing a case. Dramatic changes in problem solving or clinical reasoning are the result of structural changes in knowledge, whereas knowledge structure and quality are affected by the quality of the reasoning process that operates on the knowledge base. Clinical reasoning leaves its traces in the knowledge structure directly by strengthening or weakening links between concepts and indirectly as a result of concurrent or post hoc evaluation thereof and the knowledge actions of the learner that may follow from that.i During the first stage of expertise development, medical students acquire large amounts of knowledge about the biomedical basic sciences. They acquire concepts that are linked together in a semantic, knowledge network. Gradually, more concepts are added and refined, and more and better connections are made. Knowledge accretion and validation are the students' main concerns in this period of their study. This process takes much more time than teachers might expect. In particular, the integration and integrated use of knowledge from different domains (e.g., the clinical sciences, biochemistry, pathophysiology, and microanatomy) is not selfevident (Boshuizen and van de Wiel, 1998; Groothuis et al., 1998). During this stage, the clinical reasoning process is characterized by lines of reasoning consisting of chains of small steps commonly based on detailed biomedical concepts. An example of detailed reasoning is given in Table 5.1. It has been taken from a longer protocol in which a fourth-year medical student is dealing with a case of pancreatitis. His initial hypothesis set contained gall-bladder and pancreas disease. Apparently, this student is entertaining the hypothesis of biliary tract obstruction. First, he reasons whether the new finding about the patient's stools affects this hypothesis and decides that this is not the case. Next, three items later, he combines the information acquired and concludes that there is no inflammation (causing this obstruction) [step 1], hence, no cholecystitis [step 2], hence the biliary tract must be obstructed by something else, a stone for instance [step 3] or a carcinoma [step 4], which might be the case because the patient has lost weight [step 5].

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TABLE 5.1 Lines of Reasoning by a Fourth-Year Medical Student Case Item (Number and Text) 31. (History) Defecation: paler and more malodorous stools according to the patient 32. (History) Last bowel movement was yesterday 32. (History) Temperature: 37°C at 6 P.M. 33. (Physical examination) Pulse rate: regular, 72/min.

Think-Aloud Protocol … not so much undermines that idea … er . their frequency . and their pattern compared with colour and the like . their smell er … yes … no problems with defecation, that means in any case no constipation, which you wouldn't expect with an obstruction of the biliary tract … well yes

…

so no temperature

… er . yes … the past two … together . means that there's er no inflammation … and that would eliminate an er … an er . cholecystitis … and would rather mean an … er … obstruction of the biliary tract … caused by a stone, for instance … or, what may be the case too, by a carcinoma, but I wouldn't … although, it might be possible, lost 5 kilograms in weight …

Note. Protocol fragment obtained from a fourth-year medical student working on a pancreatitis case showing detailed reasoning steps. See Boshuizen and Schmidt (1992) for a detailed description of the experiment.

By the end of the first stage of knowledge acquisition, students have a knowledge network that allows them to make direct lines of reasoning between different concepts within that network. The more often these direct lines are activated, the more these concepts cluster together, and students become able to make direct links between the first and last concept in such a line of reasoning, skipping intermediate concepts. We have labelled this process ‘knowledge encapsulation’, a term that refers to the clustering aspect of the process and can account for the automatization involved (e.g., Boshuizen and Schmidt, 1992; Schmidt and Boshuizen, 1993). Many of these concept clusters have (semi-) clinical names, such as microembolism, aortic insufficiency, forward

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failure, or extrahepatic icterus, providing a powerful reasoning tool. Encapsulation of biomedical knowledge results in the next stage of development of clinical reasoning skills, in which biomedical knowledge has been integrated into clinical knowledge. At this stage, students' clinical reasoning processes no longer involve many biomedical concepts. Students tend to make direct links between patient findings and clinical concepts that have the status of hypotheses or diagnoses in their reasoning process. However, if needed, this encapsulated biomedical knowledge can be unfolded again, for instance when dealing with a very complicated problem. van de Wiel et al. (2000) showed that experts' clinical knowledge structures subsumed biomedical knowledge. Rikers et al. (2005) demonstrated that in expert clinical reasoning, biomedical knowledge is also activated, operating in a sort of stand-by mode. At the same time, a transition takes place from a network type of knowledge organization to a structure referred to as ‘illness scripts’. Illness scripts have three components. The first component refers to enabling conditions of disease: the conditions or constraints under which a disease occurs. These are the personal, social, medical, hereditary, and environmental factors that affect health in a positive or negative way or affect the course of a specific disease. The second component is the fault: the pathophysiological process that is taking place in a specific disease, represented in encapsulated form. The third component consists of the consequences of the fault: the signs and symptoms of a specific disease (also see Feltovich and Barrows [1984], who introduced this theoretical notion). Contrary to (advanced) novice knowledge networks, illness scripts are activated as a whole. After an illness script has been activated, no active, small-step search within that script is required; the other elements of the script are activated immediately and automatically, which results in a major cognitive advantage. While solving a problem, a physician activates one or a few illness scripts. The illness script elements (enabling conditions and consequences) are then matched to the information provided by the patient. Illness scripts not only incorporate matching information from the patient, but they also generate expectations about other signs and symptoms the patient might have. Activated illness scripts thus provide a list of phenomena to seek in history taking and in physical examination. In the course of this verification process, expected values are

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substituted by real findings, instantiating and further activating the script. Illness scripts that fail in this respect will become deactivated. The instantiated script yields a diagnosis or a differential diagnosis when a few competing scripts remain active. An example of script activation by an experienced physician, dealing with the same clinical case as the student in Table 5.1, is given in Table 5.2. The information about the patient's medical past and psycho-social circumstances (summarized in the protocol), combined with the presenting complaint, activated a few competing illness scripts: pancreatic disease, liver disease and abdominal malignancy (which he considers implausible because of the patient's age), and stomach perforation. In addition, he thought of cardiomyopathy as an effect of excessive drinking. In the course of the think-aloud protocol, he seemed to monitor the level of instantiation of every illness script. Except for gallbladder disease, no new scripts were activated. TABLE 5.2 Illness Script Activation by a Family Physician Case Item (Number and Think-Aloud Protocol Text) 8. … well, when I am visiting someone who is suffering an acute Complaint: … continuous – since when? – pain in his upper abdomen, Continuous radiating to the back, who had pancreatitis a year before … of pain in the whom I don't know for sure if he still drinks or not after that upper part course of Refusal, but of whom I do know that he still has of the mental problems, so still receives a disability benefit, then I abdomen, think that the first thing to cross my mind will be: well, what radiating to about that pancreas, … how's his liver … and also that – the back considering his age – eh it is not very likely that there will be other things wrong in his abdomen … eh … of a malign thing er nature … of course eh if he's taking huge amounts of alcohol there's always the additional possibility of a stomach eh problem, a stomach perforation … excessive drinking can also cause eh serious cardiomyopathy, which eh may cause heart defects mm I can't er judge the word ‘continuous’ very well yet in this context

Note. Protocol fragment obtained from an experienced family physician working on a pancreatitis case. Earlier, he had received information about enabling conditions such as mental problems and alcohol abuse. See Boshuizen and Schmidt (1992).

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So far, we have seen that expert and novice knowledge structures differ in many respects. As a consequence, their clinical reasoning differs as well. Medical experts, who have large numbers of readymade illness scripts that organize many enabling conditions and consequences associated with a specific disease, will activate one or more of these illness scripts when dealing with a case. Activation will be triggered by information concerning enabling conditions and/or consequences. Expert hypothesis activation and testing can be seen as an epiphenomenon of illness script activation and instantiation. These are generally automatic and ‘unconscious’ processes. As long as new information matches an active illness script, no active reasoning is required. Only in cases of severe mismatch or conflict between activated scripts does the expert engage in active clinical reasoning. During this process either illness-script-based expectations are adjusted based on specific features of the patient or the expert reverts to pure biomedical reasoning, drawing on de-encapsulated biomedical knowledge. Our old-time favourite example of deliberate script adjustment is given by Lesgold et al. (1988), who described expert radiologists' interpretations of an enlarged heart shadow on an x-ray screen. These experts took into consideration the marked scoliosis of the patient's thoracic spine, which affected the position of his heart relative to the slide. Hence, they concluded that the heart was not actually enlarged. Students, on the other hand, can rely only on knowledge networks, which are less rich and less easily activated than experts' illness scripts. They require more information before a specific hypothesis will be generated. Semantic networks must be reasoned through step by step. This is a time-consuming process and often requires active monitoring. Hence, contrary to illness scripts, the knowledge structures that students activate do not automatically generate a list of signs and symptoms that are expected. Active searching through their networks is needed to generate such a list that might verify or falsify their hypotheses. In general, students' clinical reasoning is less orderly, less goal-oriented and more time consuming, and it is based on less plausible hypotheses resulting in less accurate diagnoses than those of experts. The differences described thus far were all investigated in the context of solving cases that did not require further data collection.

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This rather artificial task has the advantage that participants can devote all their time and attention to the cognitive processing of the information given. However, authentic clinical reasoning takes place during the action of data gathering and evaluation. Recently we investigated clinical reasoning of pathologists. Similar to radiologists, their material is mostly visual: pathological slides that are inspected under a microscope. Information must be extracted by inspecting the slides at several levels of magnification. Verbal data, combined with eye movement data, suggested that students described their ‘findings’ in rather perceptual terms such as form and colour and searched for cues they could interpret in pathological terms without being able to come to a satisfactory conclusion. Experts and intermediates (residents) differed in the number of specific pathologies mentioned (intermediates mentioned more) and in the way they checked alternative scripts: experts actively searched for alternatives of their diagnosis at the end of the inspection, while intermediates appeared to have more scripts open already in the beginning (Jaarsma et al., 2014). A study by Wagenaar (2008) has shown that third-year students have great difficulty combining data collection and clinical reasoning. They are very dependent on the information the client volunteers and seem unable to reason in action. Instead, they try to collect as much information as possible, and only after they have completed the interview do they review the information collected to formulate a diagnosis. Experts, on the other hand, think on their feet, adapting their data collection to the level of verification or falsification of their hypotheses and to the time available. Table 5.3 summarizes these differences between novices, intermediates, and experts. The picture that emerges here is that novices and intermediates are handicapped in two ways: their knowledge is insufficient, and it requires extra cognitive capacity when solving problems. Both aspects negatively influence clinical problem solving; they also hinder learning. TABLE 5.3

Knowledge Restructuring, Clinical Reasoning and Levels of Expertise Knowledge

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Control

Demand

Expertise Level Novice

Knowledge Acquisition Representation and (Re)Structuring Networks Knowledge accretion and validation

Intermediate Network

Expert

Illness scripts

Clinical Reasoning

Required in Clinical Reasoning Long chains of Active detailed monitoring reasoning steps of each through reasoning preencapsulated step networks Encapsulation Reasoning Active through monitoring encapsulated of each network reasoning step Illness script Illness script Monitoring formation activation and of the level instantiation of script instantiation

on Cognitive Capacity High

Medium

Low

Teaching Clinical Reasoning Until this moment we have avoided definition of the concepts of clinical reasoning and clinical reasoning skills, first giving attention to the knowledge structures upon which these reasoning processes operate. Nor have we explicitly addressed the question of whether clinical reasoning can be taught. Yet there is huge pressure on the profession to improve the quality of diagnosis and treatment, which is apparent from the numerous publications on medical error and patient safety (e.g., Brennan et al., 1991) and evidence-based medicine (Sackett et al., 1996). Generally, clinical reasoning equals the thinking process occurring when dealing with a clinical case. Most researchers who investigate teaching clinical reasoning differentiate between different phases in the clinical reasoning process (e.g., Bowen, 2006): beginning with hypothesis generation, inquiry strategy, data analysis, problem synthesis or diagnosis and finally ending with diagnostic and treatment decision making.

Reflection Point 1 • The quality of a clinical reasoning process depends on the

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quality of the knowledge it operates on; case, knowledge and regulation together determine the quality of the result. • Knowledge networks are transformed into illness scripts as a consequence of dealing with real or simulated patients. • Encapsulating concepts integrate biomedical and clinical knowledge; to play their role in the communication with colleagues, they need to have a shared meaning. • Illness scripts are powerful cognitive structures that allow automatic processing; their validity deserves continuous attention. Clinical reasoning, its form and quality, is thus affected by the features of the case and the validity and structure of the knowledge base. Typical cases activate one illness script, plus maybe some alternatives you should always be aware of, not because of their plausibility but because of their severity (Custers et al., 1996). Atypical cases may activate several scripts that have to be sorted out by checking the script elements that are part of one but not of other scripts (Mamede et al., 2007) or that have to be further reasoned through by means of basic science knowledge (see the Lesgold et al., 1988, example described earlier). Invalid knowledge jeopardizes the validity of the whole process. Apart from these two factors, a third factor plays a role in the quality of the reasoning process. This factor is the ‘regulation of the decision-making process’ itself, which may vary between automatic and deliberate analytic processing. Decision making as a general human information processing activity has a couple of features that can make it prone to biased reasoning and others that can protect against that. For instance, the speedy activation of one illness script may lead to confirmation bias (the tendency to confirm a diagnosis or to fill the open slots in an illness script instead of searching for information that might contradict that) or to premature closure (the tendency to accept a diagnosis before other relevant options have been excluded). Also priming of one illness script (e.g., as a result of recent exposure to a similar case or a presentation in the media) leads to easier activation of the same script at the cost of others, which in turn may lead to premature closing. In the medical literature, these biases

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have been frequently described as a cause of medical error (Croskerry, 2003). The way these three factors interact works out differently on the way from novice to expert. More recently, researchers have investigated whether information processing in ‘careful mode’ helps overcome such biases. In turned out that for residents this was indeed the case but not for students (Mamede et al., 2010) and for complex cases only (Mamede et al., 2008). In a later study, Mamede et al. (2012) found that fourth-year students performed worse when stimulated to process cases very carefully than in unreflective or in ‘light’ mode; however, after 1 week, careful processing led to better diagnostic scores compared with their own previous performance and with the other groups. Other studies (e.g., Schmidt et al., 2014) directed the participants' attention to their conclusions afterward and so could override bias. Some of the manipulations studied had a positive effect on later case processing. A similar phenomenon was found by Grohnert (2017) in a very different domain, i.e., auditing. Grohnert found that having made a certain kind of mistake before and not seeing a certain task as pure routine was beneficial for later performance.ii The interventions in these studies all related to regulation of the process. The positive results related to the effects on present and future problem solving. Our conclusion from these studies is that thoughtful case processing by students as well as reflection on performance improves the quality of their knowledge structure. Discussions on the process of clinical reasoning and its fallibilities may furthermore provide students with the vocabulary and metaknowledge that can help them reflect on their performance (Kassirer, 2010). After this analysis, we return to the question how clinical reasoning expertise can be stimulated, and whether clinical reasoning skills can be taught and trained as such, or other educational measures will be needed to improve students' clinical reasoning. It might be evident that our theory and previous experiences with direct training programs suggest direct training of the different phases of clinical reasoning does not provide a general solution and that other measures are needed, as far as the reasoning component of the diagnostic process is concerned. What is more important, our theory suggests that to improve clinical reasoning, education must focus on the development of adequate knowledge

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structures. Similar conclusions permeate recent publications such as Bowen (2006) and Lubarsky et al. (2015). Hence, teaching, training, coaching, modelling, or supervising should adapt to the actual knowledge organization of the student. During the first stage in which knowledge accretion and validation take place, students should be given ample opportunity to test the knowledge they have acquired for its consistency and connectedness, to correct concepts and their connections and to fill the gaps they have detected. Students will do many of these things by themselves if they are provided with stimuli for thinking and with appropriate feedback. This stuff for thinking does not necessarily have to consist of patient problems. One could also think of short descriptions of physiological phenomena (e.g., jet lag) that have to be explained. Self-explanations (e.g., Chamberland et al., 2013) and mindmapping (Daley et al., 2016) are powerful learning instruments for students to explore and validate their knowledge. During the next stage of knowledge encapsulation, students should deal with more elaborate patient problems. As students go through the process of diagnosing a patient and afterwards explaining the diagnosis to a peer or supervisor, biomedical knowledge will become encapsulated into higher-level concepts. For instance, diagnosing a patient with acute bacterial endocarditis will first require detailed reasoning about infection, fever reaction, temperature regulation, circulation, hemodynamics and so on. Later on, a similar case will be explained in terms of bacterial infection, sepsis, microembolisms and aortic insufficiency (Boshuizen, 1989). These problems are not necessarily presented by real patients in real settings. Paper cases and simulated patients will serve the same goal, sometimes even better. Especially during the earlier stage of knowledge encapsulation, when students have to do a great deal of reasoning, it might be more helpful to work with paper cases that present all relevant information. Reasoning through their knowledge networks to build a coherent explanation of the information available, students need not be concerned whether the information on which they work is complete and valid. Later in this stage, when knowledge has been restructured into a more tightly connected format, greater uncertainty can be allowed. Finally, the stage of illness script acquisition requires experience with real patients in real settings. Research by Custers et al. (1996)

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suggests that at this stage, practical experience with typical patients (i.e., patients whose disease manifestations resemble the textbooks) should be preferred over experiences with atypical patients. With increasing knowledge, a confrontation with sets of related cases is helpful to learn about the possible manifestations of diseases, while well-chosen combination of cases with similar signs and symptoms but different underlying diseases is essential to improve the knowledge structure (Huwendiek et al., 2013). There are no empirical data that can help to answer the question of whether illness script formation requires active dealing with the patient or whether observing a doctor–patient contact could serve the same goal. On the other hand, because encapsulation and script formation go hand in hand, especially earlier on in this stage, it is probable that ‘hands on’ experience is to be preferred. Having to reason about the patient would result in further knowledge encapsulation, while direct interaction with the patient provides the opportunity for perceptual learning, adding ‘reality’ to the symbolic concepts learned from textbooks. During this phase, students might initially be overwhelmed by the information available in reality. They can easily overlook information when they do not know its relevance. This will especially affect their perception of enabling conditions. Therefore it might be helpful to draw the student's attention to the enabling conditions operating in specific patients, to make sure that their illness scripts are completed with this kind of information. Boshuizen et al. (1992) emphasize that in this stage of training a mix of practical experience and theoretical education is needed. They found that during clinical rotations students tend to shift towards the application of clinical knowledge, although it is not yet fully integrated in their knowledge base. A combination of the two ways of learning can help students to build a robust and flexible knowledge base. Thus we see that working on problems and diagnosing and explaining patient cases, applying biomedical knowledge and providing feedback on students' thinking might help them to form a knowledge system that enables efficient and accurate clinical reasoning that does not require all control capacity available (monitoring of reasoning on encapsulated concepts in a network requires less control than monitoring of reasoning on preencapsulated, detailed concepts; see Table 5.3). However, in

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practice, clinical reasoning must be performed in a context of real patients. In the end, students should be able to collect information through history taking, physical examination, and laboratory tests, guided by their clinical reasoning process, and to find a (preliminary) diagnosis in the time available. Again there are indications that students have problems with collecting information in real settings (Wagenaar, 2008). A wellorganized knowledge base is a first requirement, along with welltrained social, perceptual and psychomotor skills.iii Hence, students must learn to do their clinical reasoning and to perform these skills in a coordinated way. This again necessitates training and practice on whole training tasks that stimulate the integration of knowledge and skill into a further integrated knowledge base (Patrick, 1992). The same discussion as occurred earlier in this chapter concerning the possibility of separating knowledge acquisition and the acquisition of clinical reasoning can be repeated regarding the question of whether a well-organized knowledge base and welltrained social, perceptual, and psychomotor skills could be acquired independently. Van Merriënboer et al. (2003) have shown that good planning and design of the learning process, such that integration and automatization are fostered, are very important. A good combination of learning environments like part-task practice timely presentation of information, whole-task practice and elaboration and understanding, adjusted to the student's mastery and knowledge and the cognitive demand of the task, might be the key to success. As we have seen, working with cases plays an essential role, integrated in an educational program, based on an insight into the different obstacles that students experience at successive stages of development towards expertise. Refer to Fig. 5.1 illustrating the relationship between case, knowledge and regulation in expert clinical reasoning.

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FIG. 5.1 The relationship between case, knowledge

and regulation in expert clinical reasoning. The underlying knowledge structure can be further activated when no acceptable solution is found.

Chapter Summary In this chapter we have presented:

▪ a stage theory of development of medical expertise, ▪ differences in expert and novice knowledge structures, ▪ case examples to review the points above and ▪ implications for teaching clinical reasoning. Reflection Point 2 Consider how these points relate to your practice: • Case processing in ‘careful mode’ does not necessarily lead to

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better outcomes. • Post hoc reflection on errors in clinical reasoning improves the knowledge structure and future clinical reasoning. • Teaching with cases requires a well-designed set of cases with similar features (but dissimilar Fault) and dissimilar features (but similar Fault); this improves the richness of illness scripts as well as the network they are part of. • Teaching with cases should be adapted to the level of expertise development of the students' semantic networks, encapsulation or illness scripts.

References Boshuizen HPA. De ontwikkeling van medische expertise: een cognitief-psychologische benadering (The Development of Medical Expertise: A CognitivePsychological Approach). Doctoral thesis. University of Limburg, Maastricht, The Netherlands. 1989. Boshuizen HPA, Hobus PM, Custers EJ, et al. Cognitive effects of practical experience. Evans DA, Patel VL. Advanced Models of Cognition for Medical Training and Practice. Springer Verlag: New York, NY; 1992:337–348. Boshuizen HPA, Schmidt HG. On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices. Cogn. Sci.1992;16:153–184. Boshuizen HPA, van de Wiel MWJ. Multiple representations in medicine: how students struggle with it. van Someren MW, Reimann P, Boshuizen HPA, et al. Learning with Multiple Representations. Elsevier: Amsterdam, The Netherlands; 1998:237– 262. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N. Engl. J. Med.2006;23:2217–

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2225. Brennan TA, Leape L, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N. Engl. J. Med.1991;324:370–376. Chamberland M, Mamede S, St-Onge C, et al. Students' self-explanations while solving unfamiliar cases: the role of biomedical knowledge. Med. Educ.2013;47:1109–1116. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad. Med.2003;78:775–780. Custers EJ, Boshuizen HP, Schmidt HG. The influence of medical expertise, case typicality and illness script component on case processing and disease probability estimates. Mem. Cognit.1996;24:384–399. Daley BJ, Durning SJ, Torre DM. Using concept maps to create meaningful learning in medical education, MedEdPublish, vol. 5. [Available from:] https://doi.org/10.15694/mep.2016.000019; 2016. Feltovich PJ, Barrows HS. Issues of generality in medical problem solving. Schmidt HG, De Volder ML. Tutorials in Problem-Based Learning: A New Direction in Teaching the Health Professions. Van Gorcum, Assen: The Netherlands; 1984:128–142. Grohnert T. Judge | Fail | Learn. Enabling auditors to make high-quality judgments by designing effective learning environments. Doctoral thesis. Maastricht University, Maastricht, The Netherlands. 2017. Groothuis S, Boshuizen HPA, Talmon JL. Analysis of the conceptual difficulties of the endocrinology domain and an empirical analysis of student and expert understanding of that domain. Teach. Learn. Med.1998;10:207–216.

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Huwendiek S, Duncker C, Reichert F, et al. Learner preferences regarding integrating, sequencing and aligning virtual patients with other activities in the undergraduate medical curriculum: a focus group study. Med. Teach.2013;35:920–929. Jaarsma T, Jarodzka H, Nap M, et al. Expertise under the microscope: processing histopathological slides. Med. Educ.2014;48:292–300. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad. Med.2010;85:1118–1124. Lesgold AM, Rubinson H, Feltovich PJ, et al. Expertise in a complex skill: diagnosing X-ray pictures. Chi MTH, Glaser R, Farr MJ. The Nature of Expertise. Lawrence Erlbaum: Hillsdale, NJ; 1988:311–342. Lubarsky S, Dory V, Audétat M, et al. Using script theory to cultivate illness script formation and clinical reasoning in health professions education. Can. Med. Educ. J.2015;6:61–70. Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med. Educ.2008;42:468–475. Mamede S, Schmidt HG, Rikers RM, et al. Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert. Psychol. Res.2010;74:586–592. Mamede S, Schmidt HG, Rikers RM, et al. Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning. Med. Educ.2007;41:1185–1192. Mamede S, van Gog T, Moura AS, et al. Reflection as a strategy to foster medical students' acquisition of diagnostic competence. Med. Educ.2012;46:464–472. Patrick J. Training: Theory and Practice. Academic Press: London, UK; 1992.

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Polya G. How to Solve It. Doubleday: Garden City, NY; 1957. Rikers RM, Schmidt HG, Moulaert V. Biomedical knowledge: encapsulated or two worlds apart?. Appl. Cogn. Psychol.2005;19:223–231. Sackett DL, Rosenberg WM, Gray JM, et al. Evidence based medicine: what it is and what it isn't. Br. Med. J.1996;312:71–72. Schmidt HG, Boshuizen HPA. Encapsulation of biomedical knowledge. Evans AE, Patel VL. Advanced Models of Cognition for Medical Training and Practice. Springer Verlag: New York, NY; 1992:265–282. Schmidt HG, Boshuizen HPA. On acquiring expertise in medicine. Educ. Psychol. Rev.1993;5:205–221. Schmidt HG, Boshuizen HPA, Norman GR. Reflections on the nature of expertise in medicine. Keravnou E. Deep Models for Medical Knowledge Engineering. Elsevier: Amsterdam, The Netherlands; 1992:231–248. Schmidt HG, Mamede S, van den Berge K, et al. Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Acad. Med.2014;89:285–291. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: theory and implications. Acad. Med.1990;65:611–621. van de Wiel MWJ, Boshuizen HPA, Schmidt HG. Knowledge restructuring in expertise development: evidence from pathophysiological representations of clinical cases by students and physicians. Eur. J. Cogn. Psychol.2000;12:323–355. Van Merriënboer JJG, Kirschner PA, Kester L. Taking the load off the learner's mind: instructional design for complex learning. Educ. Psychol.2003;38:5–13.

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Wagenaar A. What and how students learn from experience. Doctoral thesis. Maastricht University, Maastricht, The Netherlands. 2008. iWe

use the term ‘learner’ to emphasize the learning process taking place. Being a learner is independent of level of expertise reached. iiGrohnert

(2017) also found that having made a mistake and being provided with a checklist led to increased confidence but not to better performance. iii

These skills have a knowledge component, which makes it quite difficult to train them in isolation, separate from knowledge acquisition.

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6

Expertise and Clinical Reasoning Gail M. Jensen, Linda J. Resnik, Amy M. Haddad

CHAPTER AIMS The aims of this chapter are to: ■ describe why expertise is essential but not sufficient for providing excellent health care, ■ discuss the critical importance of the integrative bridge across the concepts of expertise and clinical reasoning, ■ illustrate the concept of adaptive expertise and provide considerations for teaching and learning strategies and ■ propose considerations for novice development of habits of mind.

KEY WORDS Expertise Clinical reasoning Adaptive expertise

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Novice development

Introduction Our challenge in professional education is how to prepare learners who can engage in analytical thinking, skilful practice and wise judgements, often in uncertain conditions. As Schön (1987) argued, we are preparing professionals to practice in that swampy lowland of practice. In all professions, there are individuals who perform exceptionally well and who are held in high regard by their colleagues and their patients – in other words, experts. A core assumption in our chapter is that we must not separate expert knowledge from expert activity including the development of clinical reasoning and deliberate action. This is an interactive relationship in which knowledge development, analysis and action each influence the other (Woods and Mylopoulos, 2015). There is continued focus on the argument that expertise is much more of a process or continuum of development than a static state resulting from a cluster of attributes such as knowledge and problem-solving skills or high-level performance (Bereiter and Scardamalia, 1993; Cooke et al., 2010). The process of moving towards expertise is not based merely on years of experience, but there is something central about the continued development of the learner. Ideally, an enhanced understanding of what distinguishes novices from experts should facilitate learning strategies for more effective professional education. We know that experience alone does not lead to more expertise, but it is the reflection on that experience that is critical for the learner (Boshuizen et al., 2004). We begin this chapter with a ‘deconstruction of the interrelated concepts of expertise and clinical reasoning’ through a brief, analytical overview of key domains of theory and research. Next we argue that the integration of context is inherent in clinical reasoning and an essential element in adaptive expertise. From this review, we generate a working list of attributes that we believe need to be considered when talking about clinical reasoning and decision making. In the final section of the chapter, we engage in a discussion of strategies for facilitating learning and novice development in clinical reasoning that focuses on developing essential habits of mind. The goal of understanding expertise and

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clinical reasoning is, first, to promote effective reasoning in practice and, second, the translation of understanding about good reasoning into more effective teaching and student learning and ultimately the delivery of the highest-quality care.

Deconstructing the Interrelated Concepts of Expertise and Clinical Reasoning Expertise as Mental Processing and Problem Solving Expertise is a complex, multidimensional concept that has captured the interest of researchers for over 50 years (Ericsson, 2009; Rikers and Paas, 2005). The early work in this area came from cognitive psychology and accepted a tradition of basic informationprocessing capabilities of humans. Initial work in expertise concentrated on mental processing or, more simply, the conceptualization of problem solving. In deGroot's (1966) wellknown work with chess players, he began to look at differences among chess players with varying levels of expertise. He found that chess masters were able to recognize and reproduce chess patterns more quickly and accurately than novice players. Subsequent studies in areas such as chess (Chase and Simon, 1973) and physics (Chi et al., 1981) revealed that expertise depended not only on the method of problem solving but also on the expert's detailed knowledge in a specific area, ability to memorize and ability to make inferences. One of the most fundamental differences between experts and novices is that experts will bring more and better organized knowledge to bear on a problem. In medicine, the ability to determine the proper patient diagnosis was discovered to be highly dependent on the physician's knowledge in a particular clinical specialty area, called case specificity (Rikers and Paas, 2005; Schwartz and Elstein, 2008). Case specificity implies that a successful reasoning strategy in one situation may not apply in a second case, because the practitioner may not know enough about the area of the

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patient's problem. Identification of case specificity focused attention on the role of knowledge in expertise. Both clinician experience and the features of the case are factors that affect the problem-solving strategy that is used. Experts appear to have not only methods of problem solving but also the ability to combine these methods with knowledge and an understanding of how the knowledge necessary to solve the problem should be organized (Boshuizen et al., 2004; Brandsford et al., 2000; Chi et al., 1988). Experts can make connections or inferences from the data by recognizing the pattern and links between clinical findings and a highly structured knowledge base. This explains why experts tend to ask fewer more relevant questions and perform examinations more quickly and accurately than novices. Novices and intermediate subjects tend to use hypothetico-deductive processes that involve setting up hypotheses and gathering clinical data to prove or disprove them (Schwartz and Elstein, 2008). Thus less experienced clinicians tend to ask patients more questions (and in the same order) than do experts, regardless of their relevance to the case (Rivett and Higgs, 1995).

Expertise as Skill Acquisition Moulton et al. (2007) argue that there has been far too much focus on diagnostic performance and the role of experience. For health professions in which diagnosis is not the predominant decision point, there has been perhaps no more influential work in expertise than that by Patricia Benner in nursing (Benner, 1984; Benner et al., 1996, 1999, 2010). In her original work, Benner applied a model of skill acquisition developed by Hubert Dreyfus, a philosopher, and Stuart Dreyfus, a mathematician and system analyst (Dreyfus and Dreyfus, 1980). The Dreyfus' work came out of a reaction to the cognitive psychology tradition that intelligent practice is not just the application of knowledge and rules for instrumental decision making. A central premise in this work is that human understanding is a skill akin to knowing how to find one's way about the world, rather than knowing a lot of facts and rules for relating them. The Dreyfus' conception of expertise is much more focused on the context of actual practice. Several critical elements emerged

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from the Dreyfus and Dreyfus model (1980, 1996): 1) expertise is more about ‘knowing how’ (procedural knowledge, knowing how to do things) rather than knowing what (declarative knowledge, knowing information and facts), 2) expert knowledge is embedded in the action of the expert rather than propositional knowledge, 3) experience is a critical factor in the development of expertise, 4) much of expert performance is automatic and nonreflective (but when a situation is novel, experts engage in deliberation before action) and 5) intuition of experts or the knowing how to do things is both experiential and tacit. The principles of the Dreyfus and Dreyfus Model of Skill Development (Table 6.1) remain a useful framework to look at learner skill development and continue to be used across the health professions (Carraccio et al., 2008). TABLE 6.1 Aligning Teaching Strategies With Key Concepts From the Dreyfus and Dreyfus (1980, 1996) Model of Skill Acquisition Stage Novice

Key Concepts Teaching Strategies Factual, rule driven, relies Point out meaningful diagnostic on others information Cannot see whole Eliminate irrelevant information situation and highlight discriminating evidence Encourage learners to work with multiple hypotheses Advanced Objective facts Build what the learner knows, and beginner Begins to use intuition in work from common ground to concrete situations uncommon ground Uses both analytic Facilitate learners' ability to reasoning and pattern verbalize thinking and recognition differentiation of diagnoses and treatments Competent Can devise new rules Balance supervision with based on the situation autonomy in decision making Sees the big picture Expose learners to breadth and Better use of pattern depth of cases recognition with common Identify learners' developmental problems stage as may not be in the competent category across all areas Proficient Is comfortable with Expose learners to a balance of evolving situations cases, not all complex Intuitive behaviours Learners have to know when to

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replace reasoned responses Can tolerate uncertainty

Expert

Master

Can align thought, feeling, and action into intuitive problem recognition Where intuition is not developed, reasoning is applied Demonstrates practical wisdom Sees the big picture Reflects in, on and for action Demonstrates moral agency

trust intuition and when to slow down and be more analytical Facilitate learners' ability to selfregulate and know when they do not know Keep experts challenged with complex cases Apprentice expert to a master who models the skills of a true reflective practitioner

Master clinician is self-motivated and engages in lifelong learning Challenged by complex cases and habitually engaged in learning more

Source: Adapted from Benner, 1984; Carraccio, Benson, Nixon & Drestine, 2008

Key Elements in Expertise and Adaptive Expertise Although there has been prolonged debate and controversy in expertise research on the acquisition of expert characteristics, there continues to be strong agreement on the characteristics of experts (Box 6.1) (Ericsson, 2009).

Box 6.1

Characteristics of Experts ■ Experts mainly excel in their domain of expertise. ■ Experts are faster than novices in performing skills. ■ Experts can solve problems more quickly and with little error. ■ Experts have superior short-term and long-term memory. ■ Experts can see the problem in their domain at a deeper more

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principled level than novices, who have a more superficial representation of the problem. ■ Experts spend more time trying to understand the problem, and experts have strong self-monitoring skills. Although these characteristics of experts maintain consistency, educators are deeply interested in the development of the learner. How does expertise develop? What does expert practice look like? Education researchers have taken their understandings of expert processes and applied these to learners and learning. This has resulted in a distinction between routine expertise and adaptive expertise. The argument is that routine experts possess mastery of knowledge in their domain and can apply that knowledge effectively and efficiently to well-known problems, but they are challenged by novel problems. A key premise in adaptive expertise is the experts' ability to break away from the routines and be adaptable as they practice in what is called the ‘optimal adaptability corridor’ (Mylopoulos and Woods, 2009; Cutrer et al., 2016). There is a need to balance the efficiency of routine expertise with the ability to innovate and engage in progressive problem solving. A major criticism of professional education is that we overemphasize the efficiency dimension of learning and practice. We place major emphasis on certainty and right answers and little focus on how the learner can manage uncertainty (Irby et al., 2010; Shulman, 2004). How do we facilitate the development of expert-like learners who can engage in progressive problem solving and are on a path towards the development of adaptive expertise? Adaptive expertise requires: 1) an openness to reflecting on practice, 2) metacognitive reasoning skills to recognize that a routine approach to the problem will not work, 3) critical thinking to challenge current assumptions and beliefs and 4) the ability to reconstruct the problem space (Cutrer et al., 2016).

Case Study 6.1

Encouraging Adaptive Learning You have an experienced student, with an exceptional academic

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record, completing her last clinical rotation in your clinic. The student demonstrates generally good judgement and always seems to be the first to respond with routine cases. Here are some things that you can do to facilitate bringing out the adaptive learner. Try focusing your questions on reflection by framing the case as follows: “Most cases are more complex than they initially appear. If they seem too simple, ask ‘What am I missing?’ ‘What else could be going on?’ ” Challenge the student about how a routine approach to this case will not work – so now what? Have the student share the assumptions she has made about the patient. Collaborate with the student in reconstructing how you both can think about this case differently. The major components of a master adaptive learner process (Cutrer et al., 2016) include the following activities:

■ Planning: Identify a gap between what is and what should or could be; select an opportunity for learning; search for resources for learning. ■ Learning: Engage in learning; critically appraise different sources for learning; move beyond traditional learning strategies such as rereading or highlighting to more effective strategies such as spaced repetitions, elaboration and concept integration. ■ Assessing: Try out what is learned; engage in informed self-assessment that uses external feedback. ■ Adjusting: Incorporate what is learned into daily routines; reexamine new learning, and consider opportunities and barriers needed to adjust practice; determine individual versus system implementation. In summary, we know that experts are knowledgeable because

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they have extensive, accessible, well-organized knowledge and that they continue to build their practical knowledge base through a repertoire of examples, images, illness scripts and understanding that has been learned through experience (Boshuizen et al., 2004). We also see elements of the critical importance of adaptive learning as experts learn from experience by using reflective inquiry or metacognitive strategies to think about what they are doing, what worked and what did not work (Cutrer et al., 2016). Creating a learning environment that supports learners' development of creative exploration and adaptive expertise is also critical for the health professions.

Expertise and Clinical Reasoning in Everyday Practice Qualitative research methods have been central tools in investigative, grounded theory work done in several applied professions such as nursing (Benner, 1984; Benner et al., 1996, 1999, 2010), teaching (Berliner, 1986; Sternberg and Horvath, 1995; Tsui, 2003), occupational therapy (Fleming and Mattingly, 2000; Mattingly and Fleming, 1994; Robertson et al., 2015) and physical therapy (Black et al., 2010; Edwards et al., 2004; Jensen et al., 2000, 2007; Resnik and Jensen, 2003; Shaw and DeForge, 2012). These are all professions in which human interactions and care are central aspects of practice. In these studies, we find that clinical reasoning has to include both an analytical and a narrative approach as the focus of care extends beyond the identification of a diagnosis. The clinical reasoning process is iterative and ongoing. Knowing a patient, understanding his or her story, fitting the patient's story with clinical knowledge and collaborating with the patient to problem-solve are the kinds of integral components of clinical reasoning that emerge from these studies. In analysis of nursing practice, Benner found that much of expert performance in nursing emphasizes individual perceptions and decision-making abilities rather than just the performance of the skill. Benner et al. used observations and narrative accounts of actual clinical examples as primary tools for understanding the everyday clinical and caring knowledge and practical reasoning

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that were used in nursing practice. Clinical skills were identified as an overall approach to professional action that includes both perception and decision making, not just what we would think of as technical skill or technique (Benner, 1984; Benner et al., 1996, 1999, 2010). It is the integration of the knowledge with skilled know-how (i.e., knowing how to perform a skill in its real setting), along with ethical comportment, that was foundational to expertise in practice. Ethical comportment, simply stated, is the ability to engage in ethical reflection to discern moral dilemmas. This is more fully described in the last section of the chapter on habits of mind. In physical therapy, Jensen et al. developed a grounded theory of expert practice in physical therapy (Jensen et al., 2000, 2007). This model of expertise in physical therapy is a combination of multidimensional knowledge, clinical reasoning skills, skilled movement and virtue. All four of these dimensions (knowledge, reasoning, movement and virtues) contribute to the therapist's philosophy of practice. For novices, each of these core dimensions of expertise may exist, but they do not appear to be as well integrated. As novices continue to develop, each of the dimensions may become stronger, yet they may not be well integrated for proficient practice. When the expert therapist has fully integrated these dimensions of expertise, this in turn leads to an explicit philosophy of practice (Fig. 6.1) (Jensen et al., 2007).

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FIG. 6.1 Model of expertise in physical therapy. (From Jensen, G.M., Gwyer, J., Hack, L.M., Shepard, K.F., 2007. Expertise in Physical Therapy Practice, second ed. SaundersElsevier, St. Louis, MO, with permission.)

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Subsequent work by Resnik and Jensen (2003) corroborated the presence of a patient-centred approach to care in collaborative clinical reasoning and promotion of patient empowerment. At the foundation of the patient-centred approach, this research identified an ethic of caring and a respect for individuality, a passion for clinical care and a desire to continually learn and improve. The primary goals of empowering patients, increasing self-efficacy beliefs and involving patients in the care process are facilitated by patient–therapist collaborative problem solving and enhanced through attentive listening, trust building and observation. The patient-centred approach is exemplified by the therapist's emphasis on patient education and by strong beliefs about the power of education. This approach alters the therapeutic relationship and enhances patients' abilities to make autonomous choices. Resnik and Jensen (2003) reported that these efforts not only promoted patient empowerment and self-efficacy but also resulted in greater continuity of services, more skilful care and more individualized plans of care and ultimately better outcomes. Although experts in that study possessed a broad, multidimensional knowledge base, Resnik and Jensen (2003) discovered that (many) years of clinical experience and specialty certification did not appear to be mandatory in achieving expertise. This seemed to challenge a basic assertion of the Dreyfus model – that (ongoing) experience is a critical factor in development of expertise. In Resnik and Jensen's (2003) study, this was not observed, and, in fact, some therapists classified as experts were relatively new physical therapists or perhaps expert-like novices (see also Resnik and Hart, 2003). In these instances, the researchers theorized, knowledge acquisition was facilitated by work and life experience before attending physical therapy school, by being in a work environment that offered access to pooled collegial knowledge and by practitioners' values and virtues of inquisitiveness and humility, which drove their use of reflection. In-depth ethnographic work by Edwards et al. (2004) on expert physical therapists' clinical reasoning strategies has further revealed an interplay of different reasoning strategies in every task of clinical practice (e.g. interactive reasoning, diagnostic reasoning, narrative reasoning, ethical reasoning, reasoning about teaching). Rather than contrasting the cognitively based rational models of reasoning and

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interactive models of reasoning, Edwards et al. (2004) proposed a dialectic model of clinical reasoning that moves between the cognitive and decision-making processes required to diagnose and manage patients' physical disabilities and the narrative or communicative reasoning and action required to understand and engage patients and carers. Critical reflection is required with either process. In their classic ethnographic study of clinical reasoning in occupational therapy, Mattingly and Fleming (1994) originally proposed three types of reasoning in their ‘theory of the three-track’ mind: 1. Procedural reasoning (similar to hypothetical-propositional reasoning but in the case of occupational therapy the focus is on identifying the patient's functional problem and selecting procedures to reduce the effects of the problem) 2. Interactive reasoning (Active interaction and collaboration with the patient are used to understand the patient's perspective) 3. Conditional reasoning (based on social and cultural processes of understanding and is used to help the patient in the difficult process of reconstructing a life that is now changed by injury or disease) A fourth form of reasoning, narrative reasoning (Fleming and Mattingly, 2000; Mattingly and Fleming, 1994), was subsequently identified. 4. Narrative reasoning is used to describe the storytelling aspect of patient cases. Often therapists use narrative thinking and telling of a kind of ‘short story’ in coming to understand or make sense of the human experience.

Reflection Point 1 What do these examples of investigative work centred on everyday practice tell us about clinical reasoning and expertise? Across these studies, we see striking similarities that emerge from understanding the contextual factors that are essential in the

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clinical reasoning process (Box 6.2). Specifically, the integration of knowledge and context is critical for understanding and facilitating expertise. It is the human or relationship side of practice that emerges as a central component of clinical reasoning and, we would argue, part of progressive problem solving that is part of adaptive expertise.

Box 6.2

Considering Similarities Across Reasoning Studies ■ Hypothetico-deductive reasoning is used for specific procedural issues. ■ The patient is a respected and central aspect of the work. ■ Collaboration with the patient is a critical strategy in clinical reasoning and decision making. ■ Metacognitive skill (reflection) is an integral aspect of patient care. ■ Narrative is a critical tool for understanding the clinical situation including patient, carers and the clinical knowledge that is part of the story. ■ Moral agency and deliberate actions are essential elements of what it means to be ‘good’ at one's work (it is difficult to separate clinical and ethical reasoning).

Clinical Reasoning and Novice Development: Developing Habits of Mind If understanding and integrating context are so critical in the clinical reasoning process and in models of adaptive expertise, then finding ways to facilitate habits of mind is essential. The university setting does well in training the analytic ‘habits of mind’, but it does far less in developing practical skills and capacity for professional

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judgement (Colby and Sullivan, 2008). Although expert practitioners bring scientific evidence, analysis and problemsolving skills to the clinical situation, they also bring the skills of practical reasoning as they listen to patients and reflect on and make meaning of what they hear. It is this narrative understanding and practical reasoning that are informed by scientific knowledge but guided by concern for human well-being that are central to expertise. The challenge for professional education is finding the balance between the dominant analytic model of thinking with narrative thinking that can result in skilful practice and wise judgement. How do we go about developing habits of mind in our students? We argue that the relationship between patient and practitioner is a critical element of skilful ethical comportment and is foundational in expert work. Therefore focus on the patient and practitioner relationship is an essential foundation for novice development. The choice of the metaphor of foundation is important in that it emphasizes the supportive nature of ethical comportment. A foundation allows something, in this case expert work, to stand on a solid base. If something is lacking in a foundation, or is shakily built, then it will not be strong enough to withstand the stresses encountered in clinical practice. Skilful ethical comportment draws on at least three basic approaches to ethics: principled reasoning, virtue and a care orientation. A solid moral foundation includes all these approaches because an expert needs to understand moral norms and theories and to be adept at using such tools to examine moral problems and practices. However, ‘theories and principles are only starting points and general guides for the development of norms of appropriate conduct’ (Beauchamp and Childress, 2001, p. 2). An expert must also possess the virtues or character to do the right thing. If a clinician knows the correct moral action but lacks the courage or compassion to act, then the knowledge is of little significance. Lastly, a solid foundation in ethics includes the ability to discern what is worth caring about in healthcare practice. A care orientation considers what values should be pursued, nurtured or sustained and, conversely, what should be disvalued. Approaches that include only abstract principles or duties often lead to conclusions that minimize the particulars of individual circumstances that are considered morally relevant to care

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orientation. Within the realm of expert practice, the emotions of compassion, sympathy and empathy have a central place in our understanding of humane and ethical treatment of patients. Beyond these basic expressions of care, patients expect a range of emotional responsiveness from healthcare professionals that is appropriate to context. For example, in an emergency situation, most patients would prefer quick and competent action to save their lives rather than heartfelt empathy. However, it is clear that in certain cases, the emotional tone matters deeply. It is the life work of healthcare professionals to recognize those situations and adapt their emotional response to the particular needs of the patient at that time. The processes of self-reflection, reflecting together between novice and expert at the moment of a clinical encounter, or smallgroup discussion on the identification and understanding of emotions are steps in strengthening novices' capacity to hold on to and name their emotional experiences. Rather than novices being told what they should feel or should have felt (such as empathy and compassion) when interacting with patients or others, opportunities should be provided to let novices interact with simulated patients or real patients in clinically complex situations and then reflect on their experiences in their own words. Although emotions are sometimes seen as a somewhat fragile platform upon which to build such heavy obligations as moral duty or care, by attending to emotions we can see that they highlight certain aspects of a situation, serve as a mode of communication, lead to deeper self-knowledge and provide insight into motivation. Grounding and naming emotions in specific examples from novices' and experts' experiences in clinical practice begins to create a framework that legitimizes this component of the self in one's professional role. Novices can then examine, question and develop their skills in emotional sensitivity; this is an important part of ethical comportment and caring for others.

Case Study 6.2 Consider a review of a ‘routine’ clinical activity such as an

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interdisciplinary patient care meeting from an unusual perspective to raise awareness of unseen factors that can have a direct effect on the healthcare professional and patient interaction. Ask students to make a list of all kinds of power and authority of those involved in the discussion, i.e., degrees/education level, expertise, gender, seniority, title, control of resources and so on). In light of the list, as part of an individual reflection or small-group discussion, ask students to examine how people are addressed and how they speak to each other in the care meeting. What does this tell you about hierarchies of power within the team and the institution? It is essential that novices have multiple opportunities to act on ethical judgements in a safe environment and reflect not only on the reasons for a particular action or set of actions but also on the thinking and responses that led up to the action. Novices need to hear experts ‘think out loud’ after a particularly difficult exchange with a patient or colleague so that the process of arriving at a sound decision becomes more transparent. The habit of reflecting on what is going on ethically in a situation, what should be done about it and the meaning for the broader professional and public community can and must be fostered throughout professional education.

Chapter Summary ■ Expertise is not a static state, a list of specific attributes or something that is obtained through years of experience but a continuum of development and a dynamic process in which critical reflection and deliberate action are central components. ■ Adaptive expertise requires 1) an openness to reflecting on practice, 2) metacognitive reasoning skills to recognize that a routine approach to the problem will not work, 3) critical thinking to 199

challenge current assumptions and beliefs and 4) the ability to reconstruct the problem space. ■ Clinical reasoning is a complex process in which critical analysis and reflection take place in the context of the action and interaction with the patient. ■ Experts demonstrate their patient-centred focus through a consistent commitment to knowing the patient, intense listening that leads to a rich understanding of the patient's perspective and character to do the right thing. ■ The challenge in professional education is to teach the complex ensemble of analytic thinking, skilful practice and wise judgement that is required in the health professions. This skilful ethical comportment based on principled reasoning, virtue and a care orientation is the foundation of expertise. Reflection Point 2 How does this discussion fit in with your previous ideas on expertise? What are the implications for your practice and teaching or learning?

References Beauchamp T, Childress J. Principles of Biomedical Ethics. fifth ed. Oxford University Press: Oxford, UK; 2001. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley: Menlo Park, CA; 1984.

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Benner P, Hooper-Kyriakidis P, Stannard D. Clinical Wisdom and Interventions in Critical Care. WB Saunders: Philadelphia, PA; 1999. Benner P, Sutphen M, Leonard V, et al. Educating Nurses: A Call for Radical Transformation. JosseyBass: San Francisco, CA; 2010. Benner P, Tanner CA, Chesla CA. Expertise in Nursing Practice. Springer Press: New York, NY; 1996. Bereiter C, Scardamalia M. Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise. Open Court Press: Chicago, IL; 1993. Berliner D. In pursuit of the expert pedagogue. Educ Res. 1986;15:5–13. Black L, Jensen GM, Mostrom E, et al. The first year of practice: an investigation of the professional learning and development of promising young novice physical therapists. Phys. Ther.2010;90:1758– 1773. Boshuizen H, Bromme R, Gruber H. Professional Learning: Gaps and Transitions on the Way From Novice to Expert. Kluwer Academic: Norwell, MA; 2004. Brandsford J, Brown A, Cocking R. How People Learn: Brain, Mind, Experience and School. National Academy Press: Washington, DC; 2000. Carraccio C, Benson B, Nixon J, et al. From the educational bench to the clinical bedside: translating the Dreyfus Developmental model to the learning of clinical skills. Acad. Med.2008;83:761–767. Chase W, Simon HA. Perception in chess. Cogn Psychol. 1973;4:55–81. Chi MT, Feltovich PJ, Glaser R. Categorization and representation of physics problems by experts and novices. Cogn Sci (Hauppauge). 1981;5:121–152.

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Chi MT, Glaser R, Farr M. The Nature of Expertise. Lawrence Erlbaum: Hillsdale, NJ; 1988. Colby A, Sullivan W. Formation of professionalism and purpose: perspectives from the preparation for the professions program. University of St Thomas Law Journal. 2008;5:404–426. Cooke M, Irby D, O'Brien B. Educating Physicians. Jossey-Bass: San Francisco, CA; 2010. Cutrer WB, Miller B, Pusic M, et al. Fostering the development of master adaptive learners: a conceptual model to guide skill acquisition in medical education. Acad. Med.2016;92:70–75. deGroot A. Perception and memory versus thought. Kleinmuntz B. Problem Solving Research, Methods, and Theory. Wiley Press: New York, NY; 1966:19– 50. Dreyfus HL, Dreyfus SL. A five stage model of the mental activities involved in directed skill acquisition. [Unpublished report supported by the Air Force of Scientific Research (AFSC), USAF (Contract F49620-79-C-0063), University of California, Berkeley, CA] 1980. Dreyfus HL, Dreyfus SE. The relationship of theory and practice in the acquisition of skill. Benner P, Tanner CA, Chesla CA. Expertise in Nursing Practice. Springer Press: New York, NY; 1996:29–48. Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys. Ther.2004;84:312–335. Ericsson K. Development of Professional Expertise. Cambridge University Press: New York, NY; 2009. Fleming MH, Mattingly C. Action and narrative: two dynamics of clinical reasoning. Higgs J, Jones M. Clinical Reasoning in the Health Professions. second ed. Butterworth-Heinemann: Oxford, UK; 2000:54–

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61. Irby D, Cooke M, O'Brien B. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910–2010. Acad. Med.2010;85:220–227. Jensen GM, Gwyer J, Hack LM, et al. Expertise in Physical Therapy Practice. second ed. SaundersElsevier: St. Louis, MO; 2007. Jensen GM, Gwyer J, Shepard KF, et al. Expert practice in physical therapy. Phys. Ther.2000;80:28– 43. Mattingly C, Fleming MH. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. FA Davis: Philadelphia, PA; 1994. Moulton C, Regehr G, Mylopoulos M, et al. Slowing down when you should: a new model of expert judgment. Acad. Med.2007;82:S109–S116. Mylopoulos M, Woods N. Having our cake and eating it too: seeking the best of both worlds in expertise research. Med. Educ.2009;43:406–413. Resnik L, Hart D. Using clinical outcomes to identify expert physical therapists. Phys. Ther.2003;83:990– 1002. Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Phys. Ther.2003;83:1090–1106. Rikers R, Paas F. Recent advances in expertise research. Appl. Cogn. Psychol.2005;19:145–149. Rivett D, Higgs J. Experience and expertise in clinical reasoning. New Zealand J Physiother. 1995;23:16–21. Robertson D, Warrender F, Barnard S. The critical occupational therapy practitioner: How to define expertise. Aust Occup Ther J. 2015;62:68–71. Schön D. Educating the Reflective Practitioner. JosseyBass: San Francisco, CA; 1987.

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Schwartz A, Elstein AS. Clinical reasoning in medicine. Higgs J, Jones M, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Boston, MA; 2008:223–234. Shaw J, DeForge R. Physiotherapy as bricolage: theorizing expert practice. Physiother. Theory Pract.2012;28:420–427. Shulman L. The Wisdom of Practice. Jossey-Bass: San Francisco, CA; 2004. Sternberg RJ, Horvath JA. A prototype view of expert teaching. Educ Res. 1995;24:9–17. Tsui A. Understanding Expertise in Teaching. Cambridge University Press: New York, NY; 2003. Woods N, Mylopoulos M. On clinical reasoning research and applications: redefining expertise. Med. Educ.2015;49:542–544.

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SECTION 2

The Changing Context of Clinical Reasoning and Practice OUTLINE 7 The Context of Clinical Reasoning Across the Health Professions in the 21St Century 8 Changing Demographic and Cultural Dimensions of Populations Implications for Health Care and Decision Making 9 Clinical Thinking, Client Expectations and Patient-Centred Care 10 Next-Generation Clinical Practice Guidelines 11 Action and Narrative Two Dynamics of Clinical Reasoning 12 The Language of Clinical Reasoning 13 Evidence-Based Practice and Clinical Reasoning In Tension, Tandem or Two Sides of the Same Coin? 14 Methods in the Study of Clinical Reasoning

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7

The Context of Clinical Reasoning Across the Health Professions in the 21St Century Mohammad S.Y. Zubairi, Maria Mylopoulos, Maria A. Martimianakis

CHAPTER AIMS The aims of this chapter are to: ■ discuss the effect of neoliberal policies and globalization on education and practice in the health professions, ■ identify how a changing context influences identity, evidence and knowledge politics and ■ introduce critical reflexivity as a mechanism to think beyond the clinical encounter.

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KEY WORDS Globalization Neoliberalism Context Identity Reflexivity

ABBREVIATIONS/ACRONYMS EBM Evidence-based medicine IEHP Internationally educated healthcare professional

Introduction This section of the book deals with the changing context of clinical practice and clinical reasoning. In this chapter, we use a case exemplar to set the broad scene for the chapters that follow by exploring several key movements and trends emerging from contemporary neoliberal policies and globalization more broadly. We further explore the effect of these trends on knowledge and reasoning, practice models and expectations of health professions education. Subsequent chapters will address other influences, including the effect of the information evolutions, and changes in clients' expectations and input to decision making.

Reflection Point 1 In Case Study 7.1, there is an evident difference (in terms of racial background but also in English language proficiency) between the parents and the paediatrician that can be assumed to affect their interaction. What about situations in which differences between patient/families and carers are not evident? Is the verbatim message subject to influences by any sociocultural interpretation that may take place in the conversations between patient and interpreter?

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Case Study 7.1 A junior resident who completed her medical school in Ethiopia is working with a Canadian-trained paediatrician, who identifies as a White Anglo-Saxon male and wants to discuss a case he has encountered. He tells the resident about a 4-year-old boy who just started school and whose family is originally from Bangladesh. They migrated to Canada almost 2 years ago amid the 2008 economic crisis. The boy's father is an engineer and mother stays at home, and his primary language exposure in the household up until the start of school was Bengali. The boy has slowly picked up some single words in English, but the teachers are concerned about language delay even as he interacts with other Bengali-speaking children in the classroom. Parents speak enough English for the paediatrician to communicate with them, but he finds that the typical strategies he might use (i.e., humour or talking about popular culture) don't work either with the parents or the child. As a result, developing rapport has been difficult. He has worked with visibly and linguistically Bangladeshi families before and tells the resident that he is trying to approach the case the same way as with others. The paediatrician goes on to tell the resident that he struggles with explaining particular developmental diagnoses, such as autism or global developmental delay, when a language barrier is present and when cultural differences are perceived. Although this family speaks English, he wonders about the use of an interpreter particularly when time comes to give feedback to the family. He tells the resident ‘If I have an interpreter, at least I know the verbatim message is getting across, and I am being culturally sensitive’. The discourse of neoliberalism, consisting of socioeconomic policies and practices that reify and value free markets, is often linked to globalization and the amplification of the movement of services, ideas and people across borders (Spring, 2008). This variably leads to diversification and standardization across many domains including health and education. With the increased mobility of people, numerous healthcare professionals are now

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studying and/or practicing beyond the physical borders of their individual nation states. These trends have spurred the sharing of curricula and educational practices, with the goal of attaining greater standardization in the training of healthcare professionals and the delivery of health services (Timmermans and Almeling, 2009). In recent years, for example, there has been a proliferation of interprofessional, patient-centred and person-centred care models across the world calling for stronger collaborative and bidirectional interactions with patients (Haddara and Lingard, 2013; Pluut, 2016). Through such movement of people, practices and ideas, there is now an increased recognition of the internationally educated healthcare professional or IEHP. The resultant challenges IEHPs face and/or create as they try to integrate into work contexts different from the ones in which they trained requires further attention (Paul et al., 2017). This is highlighted in the initial interactions between the resident trainee in Case Study 7.1 and the paediatrician. Although discourses of globalization perpetuate the notion that the training of healthcare professionals and the object of medical practice can be standardized (Schwarz and Wojtczak, 2002; Timmermans and Epstein, 2010), the realities of being an IEHP make visible the knowledge politics underpinning contemporary healthcare educational practices. For instance, IEHPs experience exhaustive licensure requirements in contrast to those who have trained locally. Such requirements more often than not end up leaving them outside the workforce (Paul et al., 2017; Yen et al., 2016). The perceived differences in how IEHPs orient to the delivery of care often evoke client safety concerns. Thus IEHPs who do make it into the workforce often experience discrimination and stigma. Relatedly, the phenomenon of medical tourism, spurred by ideas of standardization of healthcare delivery, along with broader immigration and refugee trends, affects patient demographics across the world. As a result, healthcare professionals are frequently exposed to patients and colleagues with cultures, values, histories and beliefs related to health and illness that are different from their own (McKimm and McLean, 2011; Perfetto and Dholakia, 2010; Seeleman et al., 2009; World Health Organization, 2010). Healthcare professional educators are starting to report the

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challenges of applying curricula, pedagogies and educational tools across different healthcare contexts (Ho et al., 2011, 2012), drawing attention to how these differences affect how we operationalize ‘competence’ as a construct, particularly in relation to clinical reasoning (Hodges and Lingard, 2012).

Shifting Contexts and Identities Although the tensions discussed earlier are amplified by growing resource constraints and efficiency mandates, globalization has conceptually and materially blurred our understanding of what constitutes context, learning and expertise. This has implications for how we think about clinical reasoning. Whether homogeneity or heterogeneity is the outcome, the interconnected movement of ideas and people across borders challenges contemporary healthcare professional educators to be attentive to knowledge flow and politics. Specifically, the types of knowledge that come to be valued and/or emerge as dominant in clinical contexts affect how healthcare professionals conduct their work and how patients and their families experience health care (Bleakley et al., 2008; Hodges et al., 2009; Martimianakis and Hafferty, 2013). As one example, the physician can play several different roles in the globalized context (Box 7.1). In our case, the paediatrician, to some extent, exemplifies the ‘culturally versed global physician’ drawing from an understanding of his specific context.

Box 7.1

Discourses of the Global Physician Universal Global Physician This global physician is someone who can be trained anywhere in the world using a set of universally applicable standards of competency.

Culturally Versed Global Physician This global physician is someone who has acquired culturally specific knowledge and training through exposure and experience.

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This knowledge can be applied in culturally specific contexts (locally or internationally).

Global Physician Advocate This global physician is a socially minded individual trained to understand the economic, cultural and political determinants of health. Global physicians promote global health and use their positions of authority to advocate for marginalized populations. Derived from Martimianakis and Hafferty, 2013, p. 32.

Contemporary educators face tensions and challenges associated with reconciling competing mandates of standardization and diversification. These challenges provide researchers with a unique opportunity to clarify and critique emergent definitions of clinical reasoning. Specifically, quality control on the one hand and attunement to patient and learner needs on the other bring into focus competencies that may be at odds with one another (Gregg and Saha, 2006; Koehn and Swick, 2006). As a result, there is a rethinking of how people, including healthcare professionals, are disciplined into their profession and within a particular work context. This has implications for the positions we take in relation to clinical reasoning and expert development. Although multidirectional healthcare professional interactions and patient-centred approaches to care are by no means universal, and may often be limited to Western contexts, clinical reasoning is generally agreed to be a core standard component of practice in the health professions. The proliferation of Western models of care has affected notions of what make a ‘good’ healthcare professional and how clinical reasoning is executed. Trainees in the health professions around the world are routinely first taught a standard mix of basic science and clinical approaches through combinations of didactic lectures and small-group learning. They then have the opportunity to interact with patients they see as part of their education. Finally, they may become members of teams. This sequence in and of itself is quite standardized and has been implemented in medical schools, for example, around the world (Waterval et al., 2015). The adoption of similar approaches to clinical practice has not

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resulted in sameness in how health is experienced and health care is provided. The complexity of what healthcare professionals engage with may be influenced by structures, processes and belief systems that did not evolve or emerge from the same context as their training. This is further complicated by interprofessional models of care, which call for knowledge sharing and team problem solving. We cannot assume that everyone has been socialized into health care in the same way. Given that clinical reasoning informs a large component of a practitioner's identity, it is extremely important to consider how such an identity engages with the identities of other team members, administrators and patients (Frost and Reghr, 2013; Rummens, 2003). When the identities of the latter are different from one's own or change as a result of globalization and exposure to other health contexts, we should expect a corresponding change in how clinical reasoning occurs in day-to-day practice. Clinical reasoning in the globalized workforce then can be conceptualized as an ongoing negotiation of the discrepancies in knowledge, attitudes and practices stemming from cultural differences in what constitutes ‘good care’, as more likely than not there are marked differences between where healthcare professionals are currently located and where they originally trained (Hodges et al., 2009). It is not unreasonable, then, to speculate that healthcare professionals find themselves challenged by such discrepancies in their daily practice, as in the example of our case, and they may over time resort to choosing one way to practice (most likely the dominant way in the context of their current work) as a way to adhere to notions of quality and standardization. Clinical care guidelines are facilitative mechanisms for such standard setting, where standardization of process becomes a proxy for quality care. However, what happens when clinical care guidelines call for attention to culture and differences? How is clinical reasoning affected by growing demands to attend to sociocultural differences?

Case Study 7.2 The paediatrician, introduced in Case Study 7.1, tells the resident that there are very clear guidelines in establishing a diagnosis of

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autism or global developmental delay, and although there may be some cultural differences in how such diagnoses may be understood, ‘a diagnosis is a diagnosis is a diagnosis, and there are standardized ways to come to that diagnosis, such as intelligence testing, or using tools such as the autism diagnostic observation schedule, better known as the ADOS’. The resident, aware that she had limited training in developmental disorders in Ethiopia, has read up on autism ahead of her current placement. She quickly points out that in some cultures people do not look people directly in the eye, yet diagnostic criteria for autism include absent or reduced eye contact. The paediatrician reminds the resident that ‘they've come to me as the doctor, so although there is some room for negotiation, I need to make sure I get the diagnosis right (implying there can only be one right diagnosis) to support the child best’. The resident wonders what is meant by ‘negotiation’ in the clinical setting and is confused how to think about cultural variance in diagnostic criteria. The paediatrician goes on to tell the resident that he makes an extra effort to ensure that families who are new to Canada ‘who don't speak much English’ or ‘who don't quite know the system yet’ get connected with culturally appropriate resources. He wants to be able to meet with the child's extended family (if available) but often does not have the time and even has less time to connect with agencies directly, including those that provide therapy and the school. He gives a diagnosis and plans to see the family back in 4 to 6 months. The resident walks away asking herself ‘does that mean that culture and race only affect communication in health encounters?’

Reflection Point 2 When do race and culture factor into encounters with patients? How would one distinguish whether the challenges experienced by the white physician are related to cultural differences?

Clinical Reasoning: Valuing Evidence 213

In contrast to traditional dominant models of expertise, clinical reasoning is more frequently being defined as the ‘creative and open-ended exploration of a (clinical) problem that aims to develop an understanding of a situation … (and where) a diagnosis can be a valuable aid to reasoning, but it does not define the entirety of the reasoning process … converging (only) on an answer that is either right or wrong’ (Ilgen et al., 2016, p. 436). (See Mylopoulos and Woods, 2017, for further discussion on adaptive expertise.) This is closely related to case formulation, which may involve making a diagnosis as the paediatrician, in our case, prioritizes. However, his understanding and/or explanation of the patient's presentation only superficially address context and the perspectives available to him (including those of the parents and resident trainee from Ethiopia). In this regard, clinical reasoning, as a process of exploring problems emerging from and being influenced by globalization, becomes greater than the individual practitioner, team or organization. Although clinical reasoning could be described as application of specific algorithms and thinking very categorically about patients and their diseases (Norman, 2005), as our case highlights, globalization is challenging such a categorical and algorithmic approach. As one example, related to the developmental difficulties that children may face, it is important to consider that some diagnostic categories such as those of attention deficit hyperactivity disorder or autism may not have the same uptake as diagnoses in particular parts of the world. This has implications for both how patients from such parts of the world interact with healthcare professionals in contexts where such categories do matter. Simultaneously, how clinical reasoning may be taught to trainees in countries where such categories do not matter also needs to be addressed. Curricular strategies, diagnostic criteria and treatment algorithms developed in one context may not apply in other contexts or vice versa (Bleakely et al., 2008). Such differences are increasingly seen as important in the provision of patient-centred care models. A good example of this might be guidelines related to management of diabetes, and similarly some guidelines around end-of-life care may pose unique challenges in places where death and dying are very much governed by religious and cultural norms. In our case, a difference in eye contact is invoked by the resident highlighting the situated nature of

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knowledge. Expertise in a traditional sense, therefore, is very much a product of utilizing expert knowledge. In many contexts, clinical experts are predominantly situated within the biomedical model. Lawlor (2010, p. 169) challenges this notion of expertise by asking ‘What if expertise were considered to be more multiply located or distributed? Perhaps even more radically, what if the expertise of parents or children and adults with [specific disease] were foregrounded or privileged over other sources of knowledge … Strengthening reflections on the nature of expertise and domains of local knowledge will generate more deliberate attempts to examine multiple perspectives on understandings and events in which expertise is enacted’. Drawing from the medical education literature, on the one hand, healthcare professionals hold all power of knowing, and on the other, knowing is strategically co-constructed and distributed between the practitioner and patient (Kawamura et al., 2014). With the latter, it becomes very relevant to identify, incorporate and consider all elements, including those that are nonhuman, symbolic and discursive, at multiple levels, including the individual, organization, community and beyond (Zubairi et al., 2016). Such a reframing of expertise, to which clinical reasoning is fundamental, challenges both our definitions of the reified ‘single expert’ and what it means to make meaning of complex situations. In an evidence-based world, it allows us to expand what we value as evidence in our clinical reasoning (Mylopoulos et al., 2017). Specifically, the emergence and continual proliferation of EBM have created challenges in identifying and addressing contextspecific pockets of cultural, religious and social knowledge pertinent in the delivery of patient-centred care. Some of our own work has demonstrated how objective diagnostic formulations and treatment recommendations are determined at the expense of broader sociopolitical considerations that are patient-specific, including race, class and gender (Zubairi et al., 2016). As a result, ‘good’ healthcare professionals in today's context may be the ones who are best at practicing EBM, but using said scientific evidence runs the risk for perpetuating inequities when sociocultural knowledge related to the patient is ignored. At the same time, there are frequent ‘intercultural exchanges where hybridity has become

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significant in health care encounters, because this is where the culture of medicine collides with patients' ways of knowing and being’ (Nielsen et al., 2015, p. 2). Such varying contextual factors may challenge the practitioner to think differently about a case and influence his or her decision to take into account (or not) such elements as culture or socioeconomic differences, religion and sexual orientation. More specifically, this can challenge a healthcare professional's comfort with more standardized biomedical approaches that he or she would have learnt through education and an emphasis towards a specific diagnosis. There is evidence to suggest that although some practitioners draw more and more strictly on EBM, there are others who still rely on experience and context (Peters et al., 2016).

Critical Reflexivity and ‘Negotiation’ It has been suggested that educating healthcare professionals to be able to orient themselves to different forms of knowledge requires the practice of critical reflexivity (Ng et al., 2015). Certainly, now more than ever before, in light of global events and shifting ideologies, critical reflection allows healthcare professionals to think about their practice in deeper ways, evaluating their own beliefs, values and context within the social and systemic boundaries of their clinical practice. There is potential for practitioners to identify how they are exercising or activating the power that rests within their work (Frambach and Martimianakis, 2017). The new dominant voice has become that of the patient, and it continues to collide with the historical dominance of the healthcare professional. In the context of person- or patient-centred care, there is thus the potential of greater awareness of the hierarchies of knowledge and a relative flattening of such hierarchies. Different contexts around the world have differential attitudes to hierarchy and power among practitioners and different attitudes around avoiding uncertainty in the practice of clinical reasoning (Findyartini et al., 2016). Although there may be multiple social negotiations taking place between providers and patients who come to an encounter with different ideologies and knowledge, in the absence of an awareness of the power differentials, there may be perpetuation of inequities

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through hidden and differential expressions of racism and colonial practices (Bleakley et al., 2008). The spaces for negotiations and coconstruction of knowledge are those ‘grey’ spaces where the pendulum continues to swing between how practitioners define their own roles in clinical encounters and how their engagement with patients is defined. It is in these spaces where neoliberal constructs designed to be taught and/or measured, such as ‘cultural competency’, run the risk for ‘othering’ the patients (Betancourt, 2006; Pon, 2009; Wear, 2003) while separating clinical reasoning from important contextual factors. Such constructs are intended to standardize how care is delivered and to develop efficiencies in the health system. However, in the process, culture can become reduced in clinical encounters to a limited number of situations, for example when 1) it is visible from the perspective of the practitioner, 2) evidence and guidelines isolate culture as a variable, perpetuating race-based stereotypes, and 3) physicians use their power to treat culture as secondary to diagnostic considerations (Zubairi et al., 2016). These very spaces, therefore, permit a reconceptualization of the clinical encounter, necessitating reflection on the intended purpose of the interactions between healthcare professionals and patients/family members.

Chapter Summary The 21st century has brought with it emerging and evolving trends that directly and indirectly influence clinical reasoning in health care. These trends will be explored further in the chapters that follow. In this chapter we have outlined:

■ how neoliberal policies and globalization intersect with one another to influence clinical reasoning in current models of practice and education in health care, ■ how shifting contexts influence identities and affect the types of knowledge that are valued and 217

made dominant and ■ how practitioners can begin to reflect on the challenges and opportunities that emerge as a result of multiple trends in health care. Reflection Point 3 Is the healthcare professional, for example, the expert (and keeper of knowledge) or a resource to the client/family? Additionally, the differences that emerge between a professional and patient and the family/carer can become points of tension or conflict that can be used as starting points for ongoing reflection.

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8

Changing Demographic and Cultural Dimensions of Populations Implications for Health Care and Decision Making Jason A. Wasserman, Stephen Loftus

CHAPTER AIMS The aims of this chapter are to: ▪ articulate how shifts in the composition and character of populations promote greater complexity in diagnosis and treatment, ▪ elaborate how greater complexity in the diagnostic and treatment processes challenges traditional forms of clinical reasoning, ▪ use the examples of aging and increasing race/ethnic diversity to

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underscore the ways that demographic shifts confound traditional clinical reasoning and ▪ consider the characteristics that need to attend clinical reasoning to navigate these new complexities, including the incorporation of reflexive logics and the recognition of intersubjective processes.

KEY WORDS Demographic Aging Culture Diversity Complexity Reflexivity

Introduction Clinical reasoning is not practiced in a vacuum but rather takes place against any number of different social contexts. One of these concerns the composition and characteristics of populations of patients and the sometimes dramatic shifts these populations can undergo. Even though a healthcare professional usually is dealing at any given time only with one patient, it is often forgotten just how much the demographics of patient populations shape clinical reasoning. In this chapter, we draw attention to the importance of understanding demographics and their profound influences on clinical reasoning. Social changes, including shifts in the composition and character of populations, affect clinical reasoning through a variety of mechanisms. Ways of thinking about health are themselves nested in culturally dependent beliefs, attitudes and ways of knowing. This is true not just of the patient population but also of the healthcare professionals who provide health care. A simple example is the traditional belief that both infants and older persons

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did not feel as much pain as the rest of the population. This myth likely emerged because these age groups could not express pain easily, yet it took root in ways that dramatically affected clinical reasoning. For example, those who believed this myth were unlikely to take the need for pain management sufficiently into consideration for these patients. Such examples underscore that clinical reasoning is not simply something the healthcare professional does alone. Instead, clinical reasoning occurs within a dialogical relationship between healthcare professional and patient (at the individual level), nested in as a social structural relationship between health care and society. In this way, the clinical relationship is bidirectional, sometimes called intersubjective. The scientific basis of health care is, clearly, highly influential. At the same time, social norms and the particular tendencies of social groups place demands on health care that affect how it is practiced. For example, different beliefs and values about contraception and abortion may profoundly affect the clinical reasoning surrounding fertility and family planning. The controversies in this example are not dependent on scientific facts but on the values of those involved and, moreover, the comingling of their perspectives as they interact in a clinical dialogue. Health care and clinical reasoning, therefore, are not value-free activities. The personal and professional values of the healthcare provider and the values of his or her client play important roles. Moreover, the values that patients and providers have are partly individual but are also shaped by the wider society and especially the social groups with which they identify. Our focus in this chapter concerns how many of these wider social groups recently have experienced dramatic change. We now live in an increasingly globalized world that can affect clinical reasoning and healthcare decision making. The coming together of diverse populations with varied beliefs about the body, disease, expectations of health and normative practices places demands on the exercise of clinical reasoning. Everywhere, we encounter greater social complexity than in the past, and, like other areas of social life, clinical reasoning must shift accordingly. In what follows, we first briefly describe key social changes that affect clinical practice, particularly through introduction of new complexities. We also underscore the challenges of adapting how

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healthcare professionals think about disease and their roles in the diagnosis and treatment process with diversifying populations. We conclude with some theorizing about the future direction of these trends.

Changing Populations Providing a comprehensive description of demographic shifts in populations in various countries around the world is beyond the scope of this chapter. Instead we focus on a few key demographic shifts that highlight how increased complexity in disease epidemiology dramatically affects clinical reasoning (something elaborated later). Among many important demographic shifts, we find that a particularly instructive examination concerns how the changing age structure and the cultural diversification that attend globalization and mass migration are significantly disruptive to traditional forms of clinical reasoning. Industrialized countries around the world have, for over a century or more, witnessed marked increases in the life expectancy of their populations. Despite recent data suggesting a small decline in the United States from 78.9 years in 2014 to 78.8 years in 2015 (Xu et al., 2016), long-standing trends towards greater longevity represent greater complexity for health care and society at large. Although we often think of aging as something experienced by individuals, aggregate increased longevity can be thought of as the aging of society. As people live longer, the average age of a population increases, meaning that older people make up a greater percentage of the population. This is particularly important because social systems, including health care, often tier social support in a way that assumes healthy, working persons will care for both the young and old. At its simplest, this means that primary caregivers within family units are likely to be caring for more older family members than they did in the past. At the societal level, social service programs are funded by contributions from those in the workforce to support those who are not. As populations age, the foundations of this system of support will be more heavily stressed, a phenomenon that is already occurring in developed countries around the world and projected to increase dramatically into the future.

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Data from the European Commission in the European Union (EU) show striking degrees of population aging (EU, 2015). Between 2005 and 2015, the percentage of the EU population 65 years of age and older increased 2.3% (EuroStat, 2016). Projections find the life expectancy for men increasing from 77.6 years in 2013 to a projection of 84 years by 2060. Similarly, women in the EU lived an average of 83.1 years in 2013 but are projected to live an average of 89.1 years by 2060. Importantly, this means that the relative proportion of workers will decline by nearly 10% in light of dramatic increases in the population older than 65 years of age. In fact, individuals 65 to 79 years of age made up 13.3% of the EU population in 2013 but are projected to make up 16.6% by 2060. More striking still, individuals older than 80 years of age made up only 5.1% of the population in 2013 but are projected to make up 11.8% of the population by 2060. This is associated with significant costs, with the percentage of GDP represented by health care increasing from 6.9% to 7.8% and long-term care from 1.6% to 2.7%. Although these may seem like comparatively small increases, the problem represented by an aging population is exacerbated by the declining number of workers relative to pensioners, which was 4 : 1 in 2013 but is projected to be 2 : 1 in 2060. That is, far fewer workers will support these costlier populations. Trends from Australia and the United States parallel those of the EU. The percentage of Australians 65 years of age and older is expected to increase from 13% to 25% by 2042, representing an additional 4 million individuals in that age group (Commonwealth of Australia, 2004). Although in 2002 there were over five workers for every person older than 65 years of age in Australia, just as in the EU, by 2042, this number will decline to 2.5. In the United States, the percentage of the population 65 years of age and older increased from about 8% in 1950 to about 14% in 2013 (Martin et al., 2015). As mirrored in other Western nations, the US birth rate in the two decades after the Second World War was significantly elevated compared with the preceding decades and those that followed. Members of this ‘baby boomer’ cohort currently are aging into retirement, representing a population ‘bubble’ that will have to be supported by a relatively small number of people in the workforce. One clinical challenge in aging societies concerns the complexity of geriatric health. Older persons frequently have several chronic

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health conditions, each with its own treatment that carries potential for adverse interactions. Aging populations pose challenges for healthcare professionals on an individual level but also at the societal level where questions about funding, capitation and rationing emerge. However, aging is not the only demographic challenge to health care and clinical reasoning. Increasing race/ethnic diversity also presents new forms of complexity that challenge clinical care. This occurs not only as a result of shifting internal demographics of different nations but also because of the interlinked nature of a global society. Although there are many different often value-laden definitions of globalization, here we are primarily concerned with it as the increasingly dynamic and rapid flow of populations and their characteristics (e.g., values, beliefs and customs) across national borders. New technologies, along with increasingly interwoven economic systems, have promoted greater laxity in national boundaries and a corresponding increase in cultural diversity within countries that, historically, were culturally homogenous by comparison. For example, 20 EU countries experienced increases in the percent of foreign-born population between 2009 and 2015; 13 of those saw increases of more than 10% in that period. Australia also witnessed a marked increase in net overseas migration (Australian Bureau of Statistics, 2016). In the United States, increasing race/ethnic diversity is being driven by increases in the populations of minority groups and migration patterns, particularly of immigrating Hispanic populations. Pol and Thomas (2013, p. 87) write that ‘Current figures reveal an America that is becoming less “white”, while African American, Asian American, and American Indian/Alaskan Native populations are becoming proportionately larger’. The increasing diversity of race/ethnic groups in most developed countries holds significance for clinical reasoning that must match symptoms presented by a patient to a diagnosis and then formulate a treatment plan that not only fits within the patient's values but also that patients often must carry out themselves and with their families. Each stage of this process can be significantly affected by the cultural and social norms of the patient.

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Reasoning The foundations of clinical reasoning in the Western world are grounded in modernist forms of rationality tracing back to Cartesian thought. This means that ideas such as the logic of cause and effect are largely taken for granted. It is also often assumed that the body is a biological machine, where disease is a problem to be solved. Moreover, there is an implicit assumption that the ‘disease problem’ can always be solved if we have sufficient scientific data and the technological capacity to intervene. In this model, healthcare professionals are also assumed to be technicians who can act on the body and solve those problems (Scott, 2013). However, the demographic changes we are currently witnessing challenge this worldview. One reason for this concerns the growing incidence of chronic diseases. Acute conditions may fit well in a model that conceptualizes disease as a biophysical problem. But with chronic conditions, often the problems are never solved but instead managed over long periods of time. Well-known examples involve chronic pain and diabetes. Over time, the management often has to be adjusted and may become more complex. Individuals with diabetes can slowly deteriorate over the years, even with the best management. Patients with chronic pain can acquire other health problems that may complicate palliative care. In this situation, patients need to have significant input into the clinical reasoning required and not just provide information as part of the historytaking process. Even the many well-intentioned attempts at patientcentred care often utilize strategies of relationship building largely for the purpose of getting better diagnostic information from patients. However, traditional forms of paternalism in the clinical relationship, where physician expertise and decision making go relatively unquestioned and often utilize relatively little input from the patient beyond the eliciting of diagnostically necessary somatic information, are more fundamentally undermined in an era of both epidemiological and demographic complexity. We next take a closer look at this issue of complexity and how it manifests in both aging and increasingly diverse populations.

Epidemiological Complexity, Aging and 229

Clinical Reasoning In the later decades of the 20th century, developed nations experienced an epidemiological shift in which chronic illnesses surpassed acute illnesses as the most significant mortality threats (Hinote and Wasserman, 2016; Omran, 1971). As a class of ailments, acute conditions can be successfully treated using a relatively simple causal profile. For example, the traditional model of disease can be understood in terms of an agent (microbe or virus) infecting a host (a person or, more specifically, an organ, tissue, blood, etc.). The miracles of modern medicine developed around disrupting the causal pathways within that paradigm, either by eliminating the pathogen from the host (antisepsis) or by steeling the host against the pathogen to prevent infection (vaccination). As notions of public health took a more significant role throughout the 20th century, the role of environment was incrementally added to create the ‘epidemiological triad’, but it remained conceptualized in a relatively limited way, focusing primarily on the contexts of contagion (Dubos, 1965). Importantly, this model becomes insufficient for complex chronic diseases (at least without significant reformulation of what is traditionally meant by ‘environment’). Chronic diseases represent a paradigm shift in complexity in at least two ways. The first is ontological; that is, chronic illnesses are paradigmatically different kinds of diseases compared with acute illnesses. Chronic diseases are different kinds of entities, and therefore, the clinical reasoning required needs to be different. Although infectious diseases typically involve agents that are foreign to and distinct from the human body, most chronic illnesses involve not the presence of something foreign but elevated or depleted levels of things endemic to the human body (e.g., cholesterol or blood sugar that is too high). The targets of treatment for chronic illnesses are therefore less discrete and are natural and necessary to the body itself. Secondly, chronic illnesses emerge not from acute moments of contagion but frequently from thousands of decisions across a person's life course, each nested within different social contexts (e.g., culture, class, community, neighbourhood). Well-known examples of such decisions include smoking, alcohol use, lack of exercise and diets high in fat and sugar. These decisions

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are not always freely made. For example, low-income families may not have access to affordable or fresh food, and a poor diet may be the only realistic option. Thus values, beliefs, purchasing power, proximity to healthy or unhealthy opportunities and other social factors are fundamental causes of disease that can no longer be excised from our thinking about it (Link and Phelan, 1995). Put another way, rather than intervening in a single causal pathway (i.e., between agent and host), the multifactorial nature of chronic illness necessitates drawing together understandings of physiology and biochemistry on the one hand and sociological and psychological insights on the other. Insofar as traditional forms of clinical reasoning were able to disregard much of that information, clinical reasoning now needs to be just as multifactorial and wide ranging as the causes of disease in the contemporary epidemiological landscape. As populations age, the proportion of chronic illnesses increases. In one US study, for example, nearly 86% of adults 65 years of age and older had at least one chronic condition, over 60% had two or more, and about one-third had three or more (Ward et al., 2014). The successes of modern health care have presented new complexities that cannot be met with an old logic, and the demand on health care now concerns its attentiveness to a larger case narrative inclusive of social and psychological features of a patient's illness experience. The increasing focus on patient-centred care over the last several decades might be read as an implicit recognition of the salience of this growing complexity, but a fully delineated corresponding form of clinical reasoning has yet to take root in any widespread way. Still, efforts at elaborating and promoting narrative medicine (Charon et al., 2017; Loftus and Greenhalgh, 2010) and the generation of schemas for inductive logics inclusive of the humanistic aspects of disease today (Wasserman, 2014) suggest that attending to new forms of illness complexity and their attendant social and humanistic elements is entirely possible. Patient narratives can be read for insights into aspects of illness complexity. These include, for example, patient values or the challenges posed by contexts in which they get sick, experience illness and carry out treatment, such as their families and neighbourhoods. Utilizing such information, not just to make the patient feel more

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‘accompanied’ by the physician but rather by fully integrating it into the diagnostic and treatment processes, will be a key task for clinical practice over the coming years and decades. However, the nature of disease in aging populations and growing diversity suggest doing so is necessary. In the chronic illness era, seeking a single biomedical diagnosis on the basis of pathophysiological signs and symptoms alone is frequently no longer sufficient. For some years now, there have been calls to replace the biomedical model of clinical reasoning with a biopsychosocial model that takes social and psychological factors into account (Engel, 1977). However, even the biopsychosocial model has been critiqued as not going far enough. Morris (1998) has called for a biocultural model of health care that puts more emphasis on sociocultural factors. We would argue that this biocultural model can be part of a more relationship-centred approach to clinical reasoning that allows insights about the nature of disease and the direction of treatment to be genuinely co-created by physician and patient, but this requires the healthcare professional to abandon some assumptions about definitions of disease and his or her role as a paternalistic practitioner. Only from a basis of greater epistemological freedom—where clinicians are free to rethink traditional assumptions of clinical science to better collaborate with their patients' ways of thinking—can healthcare professionals and patients co-create an understanding of illness truly grounded in patients' experiences and values and develop a treatment plan best fit to each patient's life. This is especially true among aging populations where value-driven decisions related to cost and quality of life may call for a fundamental reconsideration of a traditionally unquestioned drive to treat all ‘problems’ (see Case Study 8.1).

Case Study 8.1 Mattie is an 83-year-old woman with a history of chronic obstructive pulmonary disease (COPD) and diabetes. Because of her diabetes, she has a very difficult time healing when she is scraped or cut and has been prone to infection of even minor skin contusions. She has discussed her end-of-life wishes with her

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primary care physician and signed a do-not-resuscitate order. On a routine visit to her pulmonologist, she notes that she's begun having palpitations in her heart. She's referred to a cardiologist, who recommends a catheter ablasion, which involves the insertion of catheter wires into the groin or neck that are sent down to the heart and which intentionally destroy the tissue causing the palpitations. The cardiologist tells Mattie and her son Mitch that the procedure is noninvasive. Mitch insists that she needs to consent to the procedure, but Mattie is hesitant. She consults with her primary care provider (PCP).

Reflection Point 1 For Case Study 8.1, articulate the various ways that this case entails different aspects of complexity (in terms of how the patient became ill, the providers that must treat her illnesses, the contexts in which she faces those illnesses and treatments, the personal values she might bring to the experience, how her age might affect her treatment goals and/or those of her providers, and so on). What challenges does each of these complexities pose for clinical reasoning? The increasingly complex pluralistic world in which practitioners meet patients today would seem to include new more reflexive forms of clinical reasoning. By ‘reflexive’, we mean forms of clinical reasoning that are more dialogical and intersubjective. Reflexivity in clinical reasoning gives permission to go beyond thinking only with simplistic cause-and-effect mechanisms, for example, by recognizing that cause and effect can be linked together in multifaceted ways in complex relationships that persist over time. This is the reality of chronic disease where complex long-term relationships need to be maintained and developed over months or years (Tasker et al., 2017). For example, in Case Study 8.1, a reflexive reconsideration of what is the best course of treatment calls us to ask whether we ought to treat the problem at all, interrogating the underlying values and goals of treatment. Building on this idea, it could even be argued that we need a form of clinical reasoning that thinks about the nature of clinical

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reasoning itself at the outset of each patient encounter, rather than carrying a universalized clinical logic into each encounter. Reflexive thinking brings social and psychological features of a patient's life into consideration but also considers other important issues. The increasing complexity of health care that comes with an aging population stresses health systems such that values-based decisions become more important, which can affect clinical reasoning. Health care resources are finite, and consideration of who gets them and who does not stretches the boundaries of the single case narrative to include the larger social context. In the early 1970s, there was both a cultural upswing in individualism and rapid scientific advances that promoted new capacities for extending life. For example, once medical science could keep someone alive on a ventilator and/or feeding tube, new questions emerged about whether it should do so and under what conditions. Similarly, as the complex illnesses of aging populations present resource challenges at the clinical, institutional and national levels, decisions about what to treat, when to treat and how to treat inevitably must account not only for the values of the patient but also the institution and the broader society in which they are made. Put another way, modernist clinical reasoning traditionally was underpinned by an assumption that if an intervention could be performed, it should be performed. Today, that assumption and others must be interrogated with a new more complex form of reflexive clinical reasoning.

Cultural Complexity, Race/Ethnic Diversification and Clinical Reasoning The traditional paradigm of clinical reasoning—a Cartesian process of diagnosis using a differential logic applied to pathophysiological symptoms (Scott, 2013)—tends not to encourage reflexivity, particularly in regard to value-laden assumptions of health care. Perhaps most generally, there is an implicit assumption that disease should be treated (as underscored in Case Study 8.1). However, the success of modern medicine and the tacit crises that emerge from these successes have underscored the value-laden nature of clinical science. Increasingly, in the era of chronic illness and long-term care, science may supply the information and the technology

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needed to intervene, but sometimes it is inappropriate to do so. With respect to these issues, our clinical reasoning needs to make use of perspectives from disciplines such as philosophy, anthropology, sociology and psychology. Shifting race/ethnic demographics further complicate such values questions because cultural experiences shape the value orientations of different groups in ways that might not align with the traditional practices of modern health care. A moving account of how different value systems can collide in health care is the tragic story of a child with epilepsy from Southeast Asia being raised in an immigrant family in the United States (Fadiman, 2012). This situation is complicated by the mass movement of people between countries as immigrants and refugees. At the time of writing, millions of refugees are seeking asylum, the largest number since the Second World War. Healthcare professionals may have to cope with both enculturated ways of thinking about health and the body and what seem like exotic physiological conditions they may have not previously encountered (see Case Study 8.2).

Case Study 8.2 An Australian medical student (George) in his final year was doing an elective study in the emergency department of a hospital in a major American city with a large immigrant population from many parts of the world. The demographic mixture brought a number of challenges that stretched his clinical reasoning ability. ‘I had a gentleman that I saw in the emergency department in the US who came in with seizures and lots of neuro signs. So I went through the history, and he's a young guy – would’ve been about 18 and so I was thinking epilepsy, brain tumour. Ran through everything quite well, obviously ordered a CT scan and it came back cysticercosis … now I would never have thought of that diagnosis in a million years. I'd never heard of it, but I was able to work through the process and do the appropriate investigations' (Loftus, 2009, p. 142). Cysticercosis is an infection by Taenia solium, the pork tapeworm, acquired by eating raw or undercooked pork containing the larval form of the worm. The larvae can migrate to the brain and cause

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epilepsy. George's patient was an immigrant from Mexico where he had presumably contracted the disease. George also described a patient with koro. ‘He [the patient] was standing in the doorway of the room, clutching himself. The registrar thought he had to go to the toilet. So he indicated the toilet, and he [the patient] said “No, no”, and he's pointing and indicating, and we have no idea what's going on, absolutely no idea, and eventually got a Laotian interpreter and from there it became quite obvious. He said “It's going to crawl back up inside me and I'm gonna die”. No matter what clinical reasoning skills that I had there I don't think I would've been prepared for it’ (Loftus, 2009, p. 148). Koro is described in South East Asia, although cases have been reported in Africa. It is the morbid fear that one's genitals are retracting into one's body and will bring about a rapid death when they do so. Sufferers have been known to go to extreme lengths to prevent what they see as their imminent demise, such as impaling the offending member or cutting it off. George's patient was, apparently, seriously considering these options. Koro should not be confused with kuru. Kuru is a neurodegenerative disorder, a form of Creutzfeldt-Jakob disease, and caused by infection by a prion. It was described in parts of Papua New Guinea in regions where cannibalism was practiced. It was contracted by eating the brains of one's close relatives as part of a funerary practice.

Reflection Point 2 For Case Study 8.2, articulate the various ways that this case entails different aspects of complexity (in terms of how the patients became ill, the providers that must treat these illnesses, the cultural values that both patient and provider bring to the encounter, the contexts in which the patient faces those illnesses and treatments, the cultural lens through which each patient might view and experience illness, the personal and cultural values each might bring to the experience and so on). What challenges does each of those complexities pose for clinical reasoning? Cultural diversity forces reconsideration of commonly held

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ethical practices, and thus of clinical decisions, in a number of ways. First, Western orientations towards ethics, generally, and medical decision making, in particular, focus squarely, and often exclusively, on the individual patient. Take, for example, the notion of truth-telling, which has, since the 1970s, been a staple of ethical practice in most Western societies. It is taken for granted that patients must be autonomous and fully informed to exercise that autonomy. However, in other countries, including many Eastern and Middle Eastern cultures (e.g., China and Japan), the orientation towards collectivities making decisions, especially in terms of the family, undercuts the individualism of Western ethics (Zahedi, 2011). As healthcare professionals treat patients from increasingly diverse backgrounds, they may need to be more reflexive about the assumptions built into their communication and their ethical decision making. Whether to disclose an illness, who serves as the primary communicator and decision maker (the patient or a family member), the terms used in the discussion – all of these affect how the relationship between the patient and the healthcare professional proceeds. These sociocultural considerations are relatively new challenges in the process of clinical reasoning, and they become even more pressing as the race/ethnic and cultural composition of various societies becomes more diverse. Other kinds of complexity regarding values decisions may take on greater import as race/ethnic and cultural diversity increases. The diagnoses and prognoses made by healthcare professionals are, at least ideally, based on scientific evidence and a scientific logic. But other orientations may reject altogether the validity of the scientific perspective or define core understandings of things like hope and futility in radically different ways. For example, cultural or religious orientations towards life may reject definitions of futility based on neurological activity, favouring the idea that the soul resides in the body as long as the heart is still beating. If this is the case, then questions about discontinuing life support must contend not only with questions about physiological futility but also broader notions about the meaning of life. It may no longer be sufficient, at least from a functional perspective, to anchor clinical reasoning solely around pathophysiological data and evidencebased science to the exclusion of the social and religious values that patients and their families bring to bear. Deciding what is medically

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futile can be fraught with complexity on pathophysiological grounds alone, but considering different orientations towards the meaning of life makes it all the more complex. There are yet other challenges facing clinical reasoning in this changing world.

Clinical Reasoning in a Postindustrial World In the preceding section, we discussed the challenges to clinical reasoning faced at the nexus of science and values in a globalizing world. But there are other challenges posed besides growing social, cultural and religious pluralism. There is a general push towards a warmer and more engaged patient-centred care that can conflict with the cold, calculating objectivity of modern science. In recent decades, different strategies designed to ‘meet the patient where he or she is’ have become popular, but there has been little thought given to how clinical reasoning fits this approach. This is particularly true where clinical reasoning is traditionally seen as a rather deductive process involving the straightforward computation of medical facts. It can be argued that demographic shifts and their attendant complexities now require healthcare professionals to function as scientists in what might be called a posttruth environment. That is, healthcare professionals must not only attend to the medical evidence in a classic process of diagnosis and prognosis, but at the same time they must weave all this together with a socially sensitive and individualized understanding of who the patient is and how he or she sees the world. This more complex view of clinical reasoning is not new; it has simply been ignored. The pioneers of evidence-based medicine recognized this when they stated that good decision making required the integration of not only the best available evidence and the expertise of the professional but also the views, values and desires of the patient (Sackett et al., 1996). Many health professions have paid attention only to gathering the best available evidence and have ignored the other two components. This is probably because of the grounding of the health professions in the biomedical sciences. Healthcare professionals are comfortable discussing and working with the best scientific evidence, but many are poorly equipped to

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talk about personal expertise and the values of patients. However, the medical humanities and social sciences do have vocabularies that can enable healthcare professionals to engage these neglected components of clinical reasoning. The huge demographic and social changes we now face mean that clinical reasoning will require social science and humanities discourses to adequately perform not only the social and emotional aspects of patient care but also its diagnostic and treatment functions. This clearly provides a warrant for more significant inclusion of the social science and humanities, something we are beginning to witness in evolving medical, nursing and allied health curricula, and on gateway examinations into these programs (e.g., the MCAT in the United States). Clinical reasoning will have to become more reflexive. It will no longer be sufficient to apply the modernist form of deductive logic to medical problems. The case studies in this chapter underscore how the challenge to our clinical reasoning is growing. In this environment of complexity, clinical reasoning becomes a negotiation, not just about what to do, where the healthcare professional tries to get the patient closest to what is in his or her own ‘best interest’, but where there are no longer a priori criteria for determining what that best interest might be. Instead, healthcare professionals in a postindustrial world must not only think about the relationship of symptoms to diagnosis but must also reflect on their own thinking about these things. This will require an unprecedented form of openness about the nature of health care, its goals and our roles as healthcare professionals (e.g., curing versus helping people die; helping the patient versus keeping the family whole).

Conclusion In this chapter, we have chosen to focus on two demographic shifts common to most Western nations that underscore the core problem of changing demographics vis-à-vis clinical reasoning. The aging of the population and increasing cultural diversity represent growing complexity at both the medical and sociological levels. Modern clinical reasoning emerged to match a set of observable pathophysiological factors to an underlying disease process, but it is poorly equipped to manage the complexity of multiple

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morbidities and pluralistic value systems. Reshaping it to match the challenges of postindustrial complexity will represent an enormous change in how healthcare professionals think.

Chapter Summary In this chapter, we have outlined:

▪ how shifts in the composition and character of populations amplify the complexity of disease and its treatment, which in turn affects clinical reasoning, ▪ how the aging of populations brings about new complexities with respect to comorbid disease processes that are difficult to navigate within clinical medicine, which has high degrees of specialization, ▪ how mass migration and resulting cultural diversity challenge not only may present clinicians with unfamiliar diseases but also bring the relevance of values and beliefs in the diagnosis and treatment processes into sharp relief and ▪ how the new terrain of disease complexity that results from demographic shifts calls for new more reflexive and intersubjective forms of clinical reasoning. Reflection Point 3 Why are chronic diseases such a challenge for clinical reasoning? Consider not only how traditional forms of clinical reasoning are mismatched to the complexity of contemporary disease but also how the increased specialization of clinical medicine confounds treatments of comorbid diseases and so on.

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Consider how other demographic shifts might affect clinical reasoning (e.g., the feminization of medicine, rising social inequality in some countries).

References

Australian Bureau of Statistics. Australia Today. http://www.abs.gov.au/ausstats/[email protected]/mf/2024.0 2016. Charon R, DasGupta S, Hermann N, et al. The Principles and Practice of Narrative Medicine. Oxford University Press: New York, NY; 2017. Commonwealth of Australia. Australia's demographic challenges. [Viewed 10 February 2017; Available from:] http://demographics.treasury.gov.au/content/discussion.asp 2004. Dubos R. Man Adapting. Yale University Press: New Haven, CT; 1965. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129– 136. European Union (EU). The 2015 aging report: projected demographic changes in the European Union. [Viewed 6 February 2017; Available from:] http://ec.europa.eu/economy_finance/graphs/201505-12_ageing_report_en.htm; 2015. EuroStat. Population age structure by major age groups: 2005 and 2015 (% of the total population). [Viewed 6 February 2017; Available from:] http://ec.europa.eu/eurostat/statisticsexplained/index.php/File:Population_age_structure_by_majo 2016. Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the

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Collision of Two Cultures. Farrar, Strauss and Giroux: New York, NY; 2012. Hinote B, Wasserman J. Social and Behavioral Science for Health Professionals. Rowman & Littlefield: Lanham, MD; 2016. Link B, Phelan J. Social conditions as fundamental causes of disease. J. Health Soc. Behav.1995;35(extra issue):80–94. Loftus S. Language in Clinical Reasoning: Towards a New Understanding. VDM Verlag: Saarbrücken, Germany; 2009. Loftus S, Greenhalgh T. Towards a narrative mode of practice. Higgs J, Fish D, Goulter I, et al. Education for Future Practice. Sense Publishers: Rotterdam, The Netherlands; 2010:85–94. Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2013. National Vital Statistics Reports, 64. [National Center for Health Statistics, Hyattsville, MD, viewed 28 March 2017; Available from:] http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf 2015. Morris D. Illness and Culture in the Postmodern Age. University of California Press: Berkeley, CA; 1998. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Mem. Fund. Q.1971;49:509–538. Pol L, Thomas R. The Demography of Health and Healthcare. third ed. Springer: Dordrecht, The Netherlands; 2013. Sackett D, Richardson S, Rosenberg W, et al. EvidenceBased Medicine: How to Practice and Teach EBM. Churchill Livingstone: New York, NY; 1996. Scott J. Complexities in the consultation. Strumberg J, Martin C. Handbook of Systems and Complexity in

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Health. Springer: New York, NY; 2013:257–278. Tasker D, Higgs J, Loftus S. Community-Based Healthcare: The Search for Mindful Dialogues. Sense: Rotterdam, The Netherlands; 2017. Ward B, Schiller J, Goodman R. Multiple chronic conditions among US adults: a 2012 update. Prev. Chronic Dis.2014;11:130389 [Available from:] http://dx.doi.org/10.5888/pcd11.130389. Wasserman J. On art and science: an epistemic framework for integrating social science and clinical medicine. J. Med. Philos.2014;39:279–303. Xu J, Murphy S, Kochanek K, et al. Mortality in the United States: 2015, NCHS data brief no. 267. [Centers for Disease Control and Prevention, Atlanta, GA] 2016. Zahedi F. The challenge of truth telling across cultures: a case study. J. Med. Ethics Hist. Med. 2011;4:11.

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9

Clinical Thinking, Client Expectations and Patient-Centred Care Della Fish, Linda de Cossart

CHAPTER AIMS The key aims of this chapter are to: ■ provide an overview of the current context of client expectations and patient-centred care that is raising new questions and responses about healthcare practitioners' expertise (HCPs), ■ demonstrate the significance of clinical thinking as the HCP's central expertise and the consequent need for this to be better understood both among HCP and also by patients who now have greater medical knowledge but still inevitably lack the professional's expert judgement and ■ identify the critical importance of the nature of the HCP professionalism focused on uncovering its transformative potential.

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KEY WORDS Professionalism Transformative professionalism Clinical thinking Professional judgement Healthcare practitioner Patient-centred care

ABBREVIATIONS/ACRONYMS NHS National Health Service (United Kingdom) GMC General Medical Council (United Kingdom) HCP Healthcare professional

Introduction This chapter contextualizes current concepts of client expectations and patient-centred care and considers their implications for practitioners. It then looks at the complexity of the HCP's expertise in clinical thinking, which goes beyond the factual knowledge laypeople can pick up from the Internet and illustrates how all HCPs and patients need to respect and understand this expertise. Finally we propose and explore four competing visions of professionalism held among both patients and practitioners, which shape how they can meet each other and offer critique and debate about a fifth ‘transformative’ view of professionalism. We believe that this transformative view of professionalism offers a new dynamic for change in patient-centred care.

Current Conceptions of Client Expectations and Patient-Centred 245

Care The aim to make the patient the key driver of his or her own healthcare plans and to be involved in the decision making has challenged thinking in the Western world professionally, fiscally and organizationally over the past 40 years (Health Foundation, 2014; National Health Service, 2015). Our thinking supports strongly the importance of the patient's best interests being at the centre of any healthcare interaction. If person-centred care is to develop further, as is likely given current organizational thinking, it will demand a change of mind-set, particularly of HCPs but also of society. There is a critical need for HCPs and patients to be involved in prevention and active care. Developing such a new mind-set and way of seeing professionalism (both in practitioner and in patients) needs to be achieved through education and learning rather than training. We argue that this focus on education is vital because this is about conduct (what we do as driven by who we are, what we believe and how we think). This is not about training (behaviour learnt by rote or through newly required and assessed competencies or protocols) (Fish, 2012). In ensuring the care of the whole patient by the whole practitioner, the importance of the education of a professional's heart and head cannot be overestimated. The spectrum of health provision is wide ranging, from prevention at one extreme to the care of the emergency patient at the other, with a wide range of support and therapeutic possibilities in between. Each domain of care (like nursing or physiotherapy) often sees itself in isolation to others and has its own language, and this brings its own dynamics and dilemmas. The fiscal divisions driven by the consumerist approach to health care in the UK's NHS over the past 30 years have exhausted imaginative thinking by diverting energy into maintaining budgets rather than seeing things anew and from a different perspective. Fire-fighting to maintain resources has become the norm. The concept of the patient as a guest (Berwick, 2009) is an attractive one and fits the model of ‘Medical Home’ being explored in the United States. The simile falls short, however, in the operating room when the surgeon inflicts harm on her patient as part of a therapeutic process. However, common to both scenarios

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are principles and themes that place the patient's well-being at the centre of the transaction and which should be honoured and respected. Little et al. (2001) identified three key areas that patients want from patient-centred care: communication, partnership and health promotion. The concept of partnership was avoided by Berwick, we think in an attempt to emphasize the importance and vulnerability of the patient. Partnership, as we see it, is a must between two (and maybe more) human beings, respecting that all bring their unique knowledge and expertise. Distortedly, however, examples of ‘patient-centred’ being ‘what the patient wants’ (rather than needs) have crept into the surgical arena, where young surgeons, unchecked, list patients for elective procedures ‘because they [the patients] want it’. The case of an 89-year-old man turning up on the day case list for a hernia repair comes to mind. The patient had an uncomplicated direct inguinal hernia that had been present, unchanged, for 30 years. The clinical thinking processes, which we see as incorporating both clinical reasoning and deliberation to come to a clinical decision (a professional judgement), are here open for critique, particularly with respect to the role of the surgeon and whether to operate or not to operate. Not to operate takes more thought and courage than just to do something. The great challenges to HCPs are not just ‘to do more stuff’ but more profoundly how we think about our roles as professionals within the healthcare specialty in which we work and how these collaborate with and support the other elements so necessary to successful therapeutic intervention. All of these ideas come against the backdrop of three key facts. 1. The exponential growth of knowledge and understanding about disease and its treatment and the resources are now freely available to all patients on the Internet. 2. The presentation and use of this information are a matter of interpretation and exist against the backdrop that it: is always incomplete; evolves during collaborative relationship with colleagues and patients; works with not on patients; involves professional judgement that opens professionals (and their patients) up to taking risks and thus to risk being wrong; is characterized by mystery at its heart; is based more upon

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uncertainty than upon total expertise; involves a spiritual dimension; opens professionals up to moral answerability; involves theorizing about practice during practice; is about creating new understanding during practice and espouses moral and ethical approaches to practice, demanding from practitioners an endless critical examination of their beliefs (de Cossart, 2005). 3. The burgeoning number of systems and processes of regulation and governance in the NHS in the UK and more generally in the Western world assume that being a HCP is a masterable practice and that pathways of care and outcomes can be predicted and controlled by regulation, thus, by these means making the care of patients safer.

How Healthcare Professionals Think: The Central Expertise of HCPs Needs to be Better Understood by Patients In health care, expertise coalesces into many distinct professional groups, each with its own traditions, ways of seeing the world and ways of educating new members into the fold. Friedson (2005) and Judge Jackson (quoted in Hilborne, 2015) challenged the perceived power that this expertise gives professionals. Further, in the care of an individual patient, each professional offers unique clinical thinking and experience when working as part of a cohesive team. The problem often is that, in our experience, these invisible thinking processes that lie at the heart of their expertise (see later in the chapter and also Chapter 36) are rarely made explicit by practitioners. Thus they cannot defend their decision making in crucial cases, nor can they provide evidence that they reflect on such processes on a regular basis and so develop their thinking and decision making. Attending to explicating this process can hugely enhance the quality of care for the patient and, additionally, the quality of care for each member of the team. In well-functioning teams, respect and understanding of each other's roles and responsibilities and thinking processes are at the heart of quality care of a patient. When the team works collaboratively,

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understanding the processes of clinical thinking as we have defined it, we believe it is a force for good and is inspirational (see also Montgomery, 2006). Over the past 40 years, the bureaucracy developed as part of each professional group establishing its individual expertise and power has been considerable. Many differing words exist to describe functions and roles across different healthcare professions, and little attempt has been made to create common ground. Our research and practice with not only doctors but also a wide range of HCPs on ‘how doctors think’ (see de Cossart and Fish, 2005; Fish and de Cossart, 2007; Thomé, 2012) have led us to identify some common ground on this element of understanding clinical thinking, because the processes, although dependent on specific expertise, are not unique to physicians and surgeons (Brigley and Jasper, 2008). An invisible complex set of decisions and tacit professional judgements underpins the fluent everyday practice of senior professionals. Their smooth and apparently unthinking performance, as observed by others, leaves unexplained the complex mental ‘workings out’ that shape their actions. In fact, without an intentional exploration of what underpins these actions, these matters may also remain tacit even to the practitioner (Fish and de Cossart, 2013). If these actions are to be understood and developed further, there must be a means of making them explicit and exploring them, because the quality of professional judgements made by HCPs are at the heart of safe patient care. Our use of ‘The Clinical Thinking Pathway’ (de Cossart and Fish, 2005; Fish and de Cossart, 2007) developed for physicians and surgeons and with other HCPs has led us to understand that professional judgements made about the care of each individual patient are case-specific and driven strongly by six key things related to the case:

■ the specific context of that case, ■ the kind of person the professional brings to that case (their personal identity, values, beliefs, spiritual focus and character traits), ■ the kind of professional the HCP brings to that 249

particular case (we all respond differently in differing contexts), ■ the range of knowledge the professional draws on within that case, ■ the therapeutic relationship developed with that patient and ■ how the professional sees the wider context of her or his role in that case. The following expands briefly on each of these. 1. The importance of the context of a case or event will involve the HCP's interpretations, with events being seen through different professional lenses. This is highly sensitive in all cases, and the failure to realize it often leads to misunderstanding and conflict. 2. The kind of person the professional brings to the case/event is founded on his or her personal values and beliefs, assumptions, feelings and attitudes, previous experience, expectations and insights and imagination. 3. The HCP's view of his or her own professionalism is a major driving influence, and we discuss this further in the next section. 4. Knowledge is often assumed to be largely empirical knowledge, facts that are irrefutable and procedural knowledge of what to do in specific circumstances. However, this is very simplistic, and we have identified fourteen forms of knowledge that need to be taken into account when exploring professional judgements. This includes self-knowledge, practice-based knowledge, intuitive knowledge, knowledge arising from improvisation and knowledge gained through practice rather than theory (de Cossart and Fish, 2005; Fish and de Cossart, 2007, 2013). Further, of course, there is a great deal of difference between knowing and understanding! This would suggest that more thought needs to be given to what professionals mean by knowledge as they discuss and explore cases.

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5. How the HCP sees his or her relationship with the patient is highly sensitive and is specific to his or her professional group. For example: the doctor and the nurse may, on a superficial level, see their roles differently, but with deeper mutual understanding they will see they are much closer together than it first appears. How each professional relates to the wider perspective of the case, not only within his or her own institution but also in the wider global context, is highly influential in his or her decision making. In our publications, we regularly use the term ‘clinical thinking’ as an overall term for the whole process from meeting the individual patient to coming to a professional judgement about his or her care. This is, of course a cycle that may happen many times during the care of the patient, because many key decisions about patient care can occur during treatment. The whole clinical thinking pathway of these processes will usually lie at the basis of all patient care but will be used with emphasis on differing points of the pathway by differing professionals at differing stages in the patient's care. Experienced professionals may run more quickly than the less experienced through the first section of the pathway as described later. Further, it is not a protocol but a guideline. We see clinical thinking as divided into two main sections. The first we call ‘clinical reasoning’ because it is more objective than the second process. Clinical reasoning, as we express it, starts – from first meeting the patient – with data collection and interpretation leading to a differential diagnosis and the forming of a general clinical solution or solutions (the right thing/s to do in general). The second process, or second half of the pathway, we call ‘deliberative thinking’, which is focused on finding a way forward for that particular patient that is tailored to his or her unique context and unique ethical, spiritual and physical needs. Although both of these main processes (clinical reasoning, which is more formulaic and uses applied science, and deliberation, which attends to the humane needs of the specific patient) are essential and mutually dependent and carried out across professional groups' thinking, the deliberative process is usually (but not exclusively) the domain of the more experienced practitioner. It requires a greater depth of development. Both need to be accounted

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for as part of good professional practice (de Cossart and Fish, 2005; de Cossart et al., 2012; Fish and de Cossart, 2013). We have expanded this further in Chapter 36 of this book. We have observed clinical teams, in a safe and supportive environment use our Clinical Thinking Model to reflect on their own responsibilities in practice. Group reflection (following an event) using our model was both revealing about professional judgement and their interpretation of the event. It helped to increase understanding about formulaic decision making and deliberative decision making. This area is not only ripe for further research but would also benefit by sharing the principles of this thinking in real practice with patients, who are at the centre of the clinical thinking but have no access to the tacit thinking processes going on in the minds of the professional/s who look after them.

The Importance of the Nature of the HCP's Professionalism: Uncovering Its Transformative Potential If client expectations and patient-centred care are to become increasing realities and successful components of health care, then the patient and clinical practitioner will need to see each other's thinking more clearly. They will need to understand themselves and each other better and create a much closer and more respectful partnership in which their equally significant but differing individual expertise can be drawn together, appreciated and used to create more effective care. This is not an institutional and managerial matter but inevitably an individual ‘bottom-up’ one, in which change will be brought about when each person enacts the change he or she wants to see happen. This not only means the practitioner must know more about himself or herself as a person and a professional but now urgently requires practitioners to build a more up-to-date conception of professionalism. Unfortunately, professionalism has recently been much maligned and distorted by many writers and is distant from the grounding concept of professions as a ‘profession of faith’ (Palmer, 2007).

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Next, we therefore review some recent conceptions of professionalism and propose the groundwork for a new and transformative version of professionalism that might better sustain practitioners in the complex demands of their work and be seen by patients as more seriously authentic.

Four Current Ways of Seeing Professionalism In this section, we characterize and explore four broad versions or categories of professionalism that we currently see in education and health care and described by the work of many recent writers (Berwick, 2009; Blond et al., 2015; Canter, 2016; Freidson, 2005; The Jubilee Centre for Character and Virtues, 2016; Palmer, 2007). These four versions run across a spectrum from three negative views about professionalism, none of which, we contend, would promote and support a genuinely closer working together of practitioner and patient. Only one view (the fourth) contains elements that are conducive to seeing the patient as a human being in a more focused way, and therefore treatment of him or her as a person evolves from a foundation of respect and trust. Our four categories are as follows. 1. ‘Professionalism discounted’ is what we have come to call the moral vacuum left within the radical consumerist view of education and health care when professionalism is sidelined (Berwick, 2009; Blond et al., 2015; Palmer, 2007). 2. ‘Managerially compliant professionalism’ is our term for the attempt to cling on to professionalism by turning it into a managerial poodle (Canter, 2016). 3. ‘Self-seeking professionalism’ is our term for the distortion of professionalism as nothing but ‘a self-serving protectionist racket’, a metaphor possibly started by George Bernard Shaw (1934) with his idea that the professions are a conspiracy against the laity (Blond et al., 2015). 4. ‘Classically shaped professionalism’, which we use to refer to professionalism based on values, virtues, character development and practice wisdom (Jubilee Centre for Characters and Virtues, 2016). This version has an

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Aristotelian basis and a language derived from preChristian times, where qualities later called spiritual values are labelled and discussed as ‘classical virtues’. The term ‘virtues’ is convenient in a multicultural society as avoiding any reference to specific religious belief. We present our interpretation of these categories of professionalism containing different ways of seeing the ‘world in which workers work’ as a sharply focused polemic to prompt discussion and debate about what kinds of professionalism would be conducive to health care that was more patient-centred. In our analysis of these four categories (Table 9.1), we have looked, for each category, at its shaping tradition, its main driving force, what it ignores or de-emphasizes, its literal or surface focus, its tacit agenda, its view of the patient, how it relates to clinical thinking and what sustains its character and succours its practitioners. Reading each column downwards reveals an overall view of each particular kind of professionalism. Thus seeing health care in consumerist terms renders care as a product, the processes of health care as conveyer belts and the patients as receivers of a satisfactory delivery. This requires streamlining practitioners' thinking into templates and pathways, leaving little place for human interaction let alone human relationship, and is kept in place as a system by extrinsic drivers and rewards. This is a world in which practitioners' compliance is required and only fiscal interests keep them going. The managerially compliant version (category 2) is much the same as this, whereas category 3, selfseeking professionalism, is seen as a system set up by professionals who are their own agents, but who in the current world are increasingly seen as both self-seeking and under siege. Clearly, in all of these three categories the role of the patient within his or her health care is sidelined. In the first category, as consumers, they judge the outcome and must be satisfied. This is not conducive to working in tandem. TABLE 9.1

A Range of Interpretations of Professionalism: for Critique and Debate

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1 2 Key Managerially Characteristics Professionalism Compliant Discounted Professionalism Shaping Industrial work Management tradition theory

3

Driving force

Deficit and defensive view of professionals' status/power (focused on maintaining power and status at all stages in the professional career as the first priority)

De-emphasizes

Literal focus

Tacit agenda

Radical consumerism in which all transactions between HCP and patient are shaped by seeing health care as a product to be delivered with utmost efficiency

All individual sense of service Values, virtues, individual as a talent HCP is employee Patient is consumer Health care is a product

Supports government power to shape

Organizational management Focusing on fulfilling the demands of what it sees as the realities of the world of work and where the individual is a cog in the machine

Individual

4 Classically Self-Seeking Shaped Professionalism Professionalism Exclusiveness of Aristotle professionalism

The positive and individual character, values and virtues of the practitioner

Being professional Fighting to within the maintain status demands of the and importance management without critique

Yields all agency to management

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To maintain exclusivity as power over the

Character education and professional wisdom/virtues (focused on bringing the best of themselves as human beings to the service of the patient, but subject to being derailed by the difficult realities of the world in which they work). That which needs to succour this when times are rough

Professionals are good people who seek the good of the patient but relying essentially on their own inner strength Virtue, values and character of HCP will assure

workforce

laity

best practice (but only while human energy lasts)

View of patient End consumer

Consumer with power who needs to be satisfied

Person who deserves best clinical treatment as practitioner deems best

One who deserves the best care and who can contribute to that care

How it relates to clinical thinking

Conceives clinical thinking as ‘serving’ what the patient wants irrespective of his or her needs!

Practitioner thinks within the bounds of his or her expertise and leaves patient in background not engaging him or her in any deliberations

Practitioner seeks best and most wise practice for each patient

Avoiding threat of losing job; seeking managers' approval and rewards sustain it. No direct succour; requires detachment from their professional beliefs and critique

Recognition of status sustains this, and selfworth and wider approval as a practitioner using critique to justify actions succour it

Recognition of integrity wisdom and expertise sustains this. Self-worth and wider approval as a person and practitioner using critical reflective practice to improve their practice succour it

What sustains and succours its practitioners

Expedient and fiscally satisfactory outcomes usually addressed through pathways and protocols that override deliberative thinking Monetary rewards and status plus laws, rules and protocols keep it in place. No direct succour beyond recognition of compliance

Only the fourth category offers a positive view of what professionals can offer their patients in working together, but even then, this is not working in tandem with the patient. Thus it is not

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surprising that even category 4 (classically shaped professionalism) is now being castigated as ‘nostalgic’ and outdated (Canter, 2016). Further, we have seen that even it fails to enable practitioners to flourish in the current realities of having simultaneously to serve various masters and to compromise their own values in relation to those of the organization they work in. Although the aims and intentions of the classically shaped version are still topical and laudable and unselfishly seek ‘the good’ of all, crucially the basic concept offers no succour, outside strength or support to its proponents when the going gets rough. We believe that this category needs further development.

Transformative Professionalism In considering the four categories discussed earlier, we came to the conclusion that what is lacking is the spiritual dimension of human identity and its transformative power. This resonates with Pellegrino (1999) and much of the work of Parker Palmer (e.g., his 1993 publication). This we contend is what enables practitioners, drawing on their inner strengths, to meet both their irritatingly difficult daily bureaucratic demands and also their patients, with a humanity augmented by ‘agape’ (a love that is without self-seeking and works from a detachment that is correctly referred to as ‘disinterested’, meaning ‘without seeking selfish gain’). It seems to us that the spiritual aspects of the human and the professional that make up the practitioner were lost (or left implicit) when the classically shaped version was reclarified in Aristotelian terms in the first decade of this century (Carr, 2003, 2004). Even at that time, something of the spiritual was still implicit in the way most people lived, but more recently our multicultural society seems to have demanded a sensitivity that requires no direct reference to such matters that are now left entirely tacit. We see an emergence of renewed sensitivity appearing now in the UK. Examples are found in Wattis and Curran (2016) and also the General Medical Council's ‘Good Medical Practice’ (2013), which make clear the importance of spirituality, although here the focus is seen only in terms of caring for patients rather than as important for the development of professional practitioners themselves. We offer, in the final column of Table 9.1, a view of

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professionalism and the world of professional work as building on the classical version through a commitment to nonphysical values that arise from a source that transcends everyday concrete physical experience and that we believe can be transforming of the professions and of the relationships between patient and practitioner. The writing of Richard Brock (2015) and Wattis and Curran (2016) supports our deliberate use of the term ‘spiritual’. It captures a set of values that work independently of the physical world and can be seen as independent of religion (although for us personally it has a Christian basis). Such values have their origins in love and humility; selflessness and self-awareness; and appreciation of beauty and wonder. The classical version attributes these values to Aristotelian thought, but they have since been transformed through the work of Christian writers like Augustine into spiritual values! Brock makes the point that some might argue that the source that originates and sustains them is ‘located beyond our everyday concrete physical experience’ and ‘might be seen as being the innate human potential for good, while most might see the source as the ultimate ground of existence, the absolute, the sacred, the divine — or simply God’. But this is not dependent on any one time period or religion. Indeed, probably, as Aldous Huxley argued (see Brock, 2015): ‘spirituality transcends time and religion and outlasts them both’. Spirituality, as Brock (2015, p. 10) says, is: a process of personal transformation through which a person seeks to integrate both the values of the world and the non-physical values that arise from a transcending source into their life. To balance the material alongside the spiritual and vice versa is to harmonise the two and make them one – much like a pair of binoculars … This is not a recipe for scrambling to the hermit's hut with nothing but sacred thoughts for company. Properly conceived, spirituality is about reconciling the difficult physical world of reality in which we still have to live and work with the one in which transcendent values can be honoured. Although difficult to put into language at one level, there are plenty of phrases in

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worldwide poetic and philosophical literature that describe this metaphorically. As our working definition, we follow Wattis and Curran (2016, p. 500) who say: Spirituality can be broadly understood as what gives meaning and purpose to life, a sense of connectedness and a source of hope. It at least includes the possibility of transcendence in the sense of moving beyond physical needs and realities. Where that paper is about attending to the spiritual needs of patients, we are more concerned here with the needs of professionals themselves and their personal reservoirs of energy and hope that sustain them in the spirit of public service during the many difficult times found within daily practice and in seeking to meet the patient halfway. We see this not as ‘being trained in resilience’, where the means to rise above and beyond difficulties as a professional comes from a newly learnt ‘skill’ added to our repertoire but as stemming from the kind of person we seek to be and become and the inner source that feeds our being. This is what many argue is the means to cope with the world by bringing together ‘the things of Time with the Timeless’ (that is: confront the temporary material or physical matters of this world with enduring values from beyond it) so that the physical is transformed. As Plato wrote, ‘the human soul sits on a horizon between Eternity and Time and is nourished by both’ (Brock, 2015, p. 7). Equipped with this explanation and now reading across the table, clear distinctions of key characteristics are visible between each professional category. Further, the bottom row of the table particularly shows an interesting continuum from the need in category 1 for extrinsic motivation and legal requirements to keep the professional in place through to category 5, where what is needed to keep the system working well is the practitioners' own character, drive and abilities, supported by self-awareness and the recognition of strength from human and spiritual dimensions nurtured by critical reflective practice (Fish and de Cossart, 2013). Such a practitioner can then meet the patient on human and humane terms, with physical and spiritual needs attended to in a trusted partnership. The key to all this is who you are not what

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training you have had in new strategies to conform to the newest move in patient care. This concept of transformational professionalism links with work we have already done (helped by Campbell, 1984), on the person and professional being an influential dimension within the clinical thinking processes (de Cossart and Fish, 2005; Fish and de Cossart, 2007, 2013). The concept goes beyond our earlier work, in that we are now beginning to try to explore the importance in the life of a professional of agape, of disinterest and of detachment. This is about seeing the world we work in as only a part of life as a whole. We fully recognize that this is aspirational rather than totally achievable, but at least that will enable professionals to aspire to the best and to be succoured when their journey becomes temporarily almost too wearying to be continued. Our experience over the past 2 years of exploring some of these ideas with 75 senior medical practitioners as part of a teaching program has convinced us that there is a considerable need for this element of professional practice to be explored. The positive energy released in our learners' response to the matter has inspired and energized us to pursue this further. We invite you to explore the significance of all this for yourself by reading and critiquing Table 9.1 and responding to Reflection Point 1.

Chapter Summary In this chapter we have addressed the following:

■ The current dilemma for all HCPs in battling with more worthwhile partnership with patients is that many of the things that they hold dear as being a good professional and humane carer will be lost if they do not take time to consider and share the unmeasurable but highly significant elements of their practice. ■ We explored the concept of the HCP's clinical thinking, expertise and ability to engage in 260

patient-centred care. ■ We argued that HCPs have had a predominant focus on traditional conceptions of professionalism and that there has been little attention to the spiritual qualities in their practice. ■ We proposed our Clinical Thinking Pathway and the idea of ‘Transformative professionalism’ as resources to be a means of exploring and developing the spiritual elements of professionalism and of sustaining and energizing the professional in providing whole patientcentred care. Reflection Point 1 1. Read through Table 9.1, and reflect on how this might help you to express your professional identity more authentically and to confront the personal demands of providing patientcentred care. 2. We suggest that ‘The key to all this is who you are, not what training you have had in new strategies to conform to the newest move in patient care’. Critique this statement. 3. How would you prepare to teach these ideas to those preparing for or engaged in patient-centred care? 4. What resources might you need to help you teach this in real practice, and how does what we offer here resonate with what follows in this book?

References Berwick DM. ‘Patient-centred’ should mean: confessions of an extremist. Health Aff. (Millwood). 2009;28:w555–w565.

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Blond P, Antonacopoulou E, Pabst A. In professions we trust: fostering virtuous practitioners in teaching, law and medicine. [ResPublica, London, UK. Viewed 20 January 2016; Available from] http://www.respublica.org.uk/wpcontent/uploads/2015/02/In-Professions-WeTrust.pdf; 2015. Brigley S, Jasper M. An evaluation of: a multidisciplinary approach to surgical education and training: report for the Department of Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, UK. 2008. Brock R. Four Quartets: TS Eliot and Spirituality. [Patrician Press, Manningtree, Essex] 2015. Campbell A. Moderated Love: A Theology of Professional Care. SPCK: London, UK; 1984. Canter R. The new professionalism. Bulletin. 2016;10– 13. Carr D. Making Sense of Education: An Introduction to the Philosophy and Theory of Education and Teaching. Routledge Falmer: London, UK; 2003. Carr D. Rival conceptions of practice in education and teaching. Dunne J, Hogan P. Education and Practice: Upholding the Integrity of Teaching and Learning. Blackwell Publishing: Oxford, UK; 2004. de Cossart L. A question of professionalism: leading forward the surgical team. Ann. R. Coll. Surg. Engl.2005;87:238–241. de Cossart L, Fish D. Cultivating a Thinking Surgeon: New Perspectives on Clinical Teaching, Learning and Assessment. TFM Press: Shrewsbury, UK; 2005. de Cossart L, Fish D, Hillman K. Clinical reflection: a vital means of supporting the development of wisdom in doctors. Curr. Opin. Crit. Care. 2012;18:712–717.

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Fish D. Refocusing Postgraduate Medical Education: From the Technical to the Moral Mode of Practice. Aneumi Publications: Cranham, Gloucestershire; 2012. Fish D, de Cossart L. Developing the Wise Doctor. Royal Society of Medicine Press: London, UK; 2007. Fish D, de Cossart L. Reflection for Medical Appraisal: Exploring and Developing Your Clinical Expertise and Professional Identity. Aneumi Publications: Cranham, Gloucestershire; 2013. Friedson E. Professionalism: The Third Way. Polity Press: Oxford, UK; 2005. General Medical Council. Good medical practice. [Viewed 17 May 2016; Available from] http://www.gmcuk.org/guidance/good_medical_practice/apply_knowledge.as 2013. Health Foundation. Patient centred care made simple: the health foundation inspiring improvement. [Viewed 13 January 2017; Available from] http://www.health.org.uk/sites/health/files/PersonCentredCa 2014. Hilborne N. Jackson: ‘professional negligence’ could disappear as attitudes to professionals change. [Legal Futures (online). Viewed 7 October 2016; Available from] http://www.legalfutures.co.uk/latestnews/jackson-professional-negligence-coulddisappear-as-attitudes-change; 2015. The Jubilee Centre for Character and Virtues. The Jubilee Centre for Character and Virtues statement on character, virtue and practical wisdom in the professions. [University of Birmingham, UK. Viewed 15 October 2016; Available from] http://www.jubileecentre.ac.uk/userfiles/jubileecentre/pdf/St

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2016. Little P, Everitt H, Williamson I, et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ. 2001;322:1–7. Montgomery K. How Doctors Think: Clinical Judgement and the Practice of Medicine. Oxford University Press: Oxford, UK; 2006. National Health Service (NHS). The NHS Constitution: The NHS belongs to us all. [Department of Health, London, UK. Viewed 13 January 2017; Available from] https://www.gov.uk/government/uploads/system/uploads/a 2015. Palmer PJ. To Know as We Are Known: Education as a Spiritual Journey. HarperCollins: San Francisco, CA; 1993. Palmer PJ. A new professional: the aims of education revisited. Change: The Magazine of Higher Learning. 2007:6–13 [39]. Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J. Med. Philos.1999;24:243–266. Royal College of Nursing. Spirituality in nursing care: a pocket guide. [Viewed 23 January 2017; Available from] https://www.rcn.org.uk/professionaldevelopment/publications/pub-003887; 2012. Shaw GB. The Doctor's Dilemma. Odhams Press Ltd: Watford, UK; 1934. Thomé R. Educational Practice Development: An Evaluation (an exploration of the impact on participants and their shared organisation of a Postgraduate Certificate in Education for Postgraduate Medical Practice 2010–2011). [Aneumi Publications,

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Cranham, UK] 2012. Wattis J, Curran S. The importance of spirituality in caring for patients. Br. J. Hosp. Med.2016;77:500– 501.

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10

Next-Generation Clinical Practice Guidelines Karen Grimmer, Stephen Loftus, Janine Margarita Dizon

CHAPTER AIMS The aims of this chapter are to: ▪ Reflect on the past decade of activity in clinical practice guidelines (CPGs) and ▪ Consider the ways in which the next generation of CPGs will integrate with clinical decision making.

KEY WORDS Clinical reasoning Clinical practice guidelines Evidence-based practice Evidence implementation

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ABBREVIATIONS/ACRONYMS ACA Adopt, Contextualise, Adapt approach CPGs Clinical practice guidelines DALYs Disability-Adjusted Life Years EBP Evidence-based practice EIP Evidence-informed practice G-I-N Guidelines International Network HIC High-income countries iCAHE International Centre for Allied Health Evidence IOM Institute of Medicine LMIC Lower- to middle-income countries NICE National Institute for Health and Care Excellence PROMS Patient Reported Outcome Measures QALYs Quality-Adjusted Life Years SAGE South African Guidelines Excellence SIGN Scottish Intercollegiate Guideline Network WHO World Health Organization

Introduction Clinical practice guidelines (CPGs) have long been considered an important element of good quality health practice (Field and Lohr, 1990). Since the last edition of this book, CPG activity internationally has escalated. New terms, new methods and more in-depth understanding have emerged regarding how research evidence can better inform clinical practice. As a consequence, much new work is presented in this chapter. This progress has been underpinned by activities of Guidelines International Network (G-IN),i a vibrant international group of CPG enthusiasts who

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collaborate to develop better ways of CPG writing, presentation, implementation and evaluation, with the aim of fostering safe and effective patient care around the world.

Frameworks of Clinical Practice Guidelines Application Since 2000, the Sackett et al. (2000) evidence-based practice (EBP) model has been used to promote the balance of research evidence, clinical judgement and patient choices within local contexts to ensure the correct decisions are made for individual patients. In 2009 Satterfield et al. proposed the notion of evidence-informed practice (EIP) (Fig. 10.1). This model recognizes the inherent uncertainties in current best research evidence, clinical judgement and patient responses to, and understanding of, the evidence, within local contexts. This model may better align with allied health practice because of variability and uncertainties in the research evidence, patient choice and values and clinician reasoning, training and judgement.

FIG. 10.1 The evidence-informed practice model. (From Satterfield, J.M., Spring, B., Brownson, R.C., Mullen, E.J., Newhouse, R.P., Walker, B.B., Whitlock, E.P., 2009. Toward a transdisciplinary model of evidence-based practice. Milbank Q. 87, 368–390, with permission.)

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Reflection Point 1 CPGs need to be written in a manner that helps clinicians to integrate best evidence, their own clinical judgement, the desires and values of the patient within local contexts. Do you use CPGs regularly in your practice as a ‘one-stop-shop’ for evidence? Have the CPGs you are familiar with been written this way? How did the way they were written affect your ability to use them in your clinical reasoning?

Current State of Play in Clinical Practice Guidelines The evolution of CPGs is exemplified by changing definitions over time. The Institute of Medicine (IOM) described CPGs in 1990 as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’ (Field and Lohr, 1990, p. 38). This definition was updated in 2011 to emphasize the need for rigorous methodology: ‘Clinical guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options’ (Graham et al., 2011, p. 1). CPG research has rapidly evolved since then, with a current definition: ‘Guidelines are considered a convenient way of packaging evidence and presenting recommendations to healthcare decision makers’ (Treweek et al., 2013, p. 2). Over the past decade, respected CPG developers’ organizations have been established, such as the National Institute for Health and Care Excellence (NICE)ii and the Scottish Intercollegiate Guideline Network (SIGN).iii These and other international CPG writing groups have produced so many CPGs on so many topics that it would be difficult not to find some CPG for a clinical question, somewhere. There are also regularly updated repositories of CPGs such as NICE, SIGN, the International Centre for Allied Health Evidence (iCAHE) (University of South Australiaiv) and the United States of America Guidelines Clearing House.v Professional associations also often host discipline-specific CPGs, but these may

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only be available to members. Identifying useful CPGs may require lateral thinking. For example, recommendations on how best to treat chronic low back pain may be found in a condition-specific CPG, or they may be found in a CPG about chronic pain or musculoskeletal disorders.

Reflection Point 2 Well-developed CPGs can be readily found in a number of freely available Internet sites. Which guideline repositories do you use to find CPGs relevant to your area of practice?

Critical Elements of Using Clinical Practice Guidelines Before implementing the recommendations reported in any CPG, end-users should first question its quality. Thus end-users should be comfortable in critically assessing a CPG and in making informed judgements about its usefulness to their clinical contexts. The recently published standards for CPG writing are considered industry best practice (Schünemann et al., 2014). A good quality CPG should be easy to read and navigate. It should be written by credible methodologists, working with clinical experts. CPGs must have a clearly defined purpose and must target group and end-users. A good quality CPG should have a comprehensive Methods section that outlines a comprehensive process by which the relevant evidence was identified, collated, critically appraised to detect bias and transparently summarized into recommendations. A good CPG may also provide implementation strategies, and many quality improvement initiatives are often now linked with implementation and evaluation of CPGs. Kredo et al. (2016) provide a useful explanation of the current situation in CPG activities. Table 10.1 provides examples of tools to assist CPG writers. TABLE 10.1 Selected Advice to Support Clinical Practice Guideline Writing and

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Implementation Term Critically appraising CPG quality

Explanation iCAHE tool: A 14-item binary tool developed for clinicians, managers and policy-makers to assess the methodological quality of a CPG.

Grades of Recommendation, Assessment, Development and Evaluation (GRADE): A detailed decision-making approach that establishes risk for bias and how this translates to clinical decision making Communicating Developing and Evaluating Communication findings Strategies to Support Informed Decisions and Practice Based on Evidence project (http://www.decide-collaboration.eu) (DECIDE) GuideLine Implementability Appraisal (GLIA) (BridgeWhiz) Fitting CPG ADAPTE recommendations Adopt, Contextualize, Adapt (ACA) to local contexts approach

References Grimmer et al. (2014); Dizon et al. (2016) Schünemann et al. (2014)

Treweek et al. (2013) Shiffman et al. (2005) The ADAPTE Collaboration (2009); Dizon et al. (2016)

CPG, clinical practice guideline; iCAHE, International Centre for Allied Health Evidence.

With so much freely available information on CPGs methods, one could expect that the concerns raised by Shaneyfelt et al. (1999) about the quality of CPGs would have been addressed by now. However, a review in 2015 of the methodological quality of 16 current primary care CPGs developed by professional associations in South Africa, government agencies and academic institutions highlighted variability in CPG quality and construction (Grimmer et al., 2016a; Machingaidze et al., 2017). This highlights the need to educate CPG writers around the world about CPG quality elements and how to address them.

Reflection Point 3 It is essential to determine the quality of the CPGs that you use, particularly in terms of how well they have been constructed and the recommendations reported. Do you assess the quality of the CPGs that you use? What are the most important aspects of CPG quality to you?

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Next-Generation Clinical Practice Guidelines The South African Guidelines Excellence (SAGE) project team from South Africa reports innovative approaches to CPG writing, presented in a manner relevant to primary care in developing countries (Grimmer et al., 2016b; Machingaidze et al., 2015). The Project SAGE team proposed a three-tier CPG model, with Tier 1 being the evidence base, Tier 2 being ‘expert’ input to the evidence base to ensure its applicability and generalizability to local circumstances and Tier 3 being CPG ‘products’ for end-users. There may be more than one Tier 3 product from a CPG depending on end-user needs (e.g., treatment protocols, patient decision-making tools, short-form recommendations, information sheets). See the first column in Fig. 10.2.

FIG. 10.2 The clinical practice guideline tier approach.

Kumar et al. (2010) spoke about the confusion around CPG terminology and the SAGE tiered approach attempts to demystify and standardize this. Project SAGE highlighted lower- to middleincome countries (LMICs). The high-income countries’ (HICs) CPGs generally have extensively researched Tier 1 material, written with appropriate Tier 2 input from relevant end-users but with little

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focus on Tier 3 material. This might be a set of recommendations published in an academic journal or made available on a phone ‘app’ for clinical end-users. Conversely, in LMICs there seems to be a greater interest in Tier 3 products (how to do it) than in the evidence base (Machingaidze et al., 2015). When there is limited money for CPG writing, as often occurs in developing countries, the Project SAGE model offers an efficient and transparent approach to constructing and presenting CPGs. The Project SAGE three-tier CPG model could increase CPG construction efficiency.

Reflection Point 4 Terminology around CPG writing varies, and there is no standard agreement about what constitutes a ‘full’ CPG and what constitutes components of a CPG (such as a protocol). What terminology do you use when you discuss ‘guidance’ from CPGs?

Implementation It is widely recognized that simply producing a CPG will not ensure that its recommendations are adopted by end-users. Many theories have been developed in the past decade to improve CPG implementation, and there is consistent evidence of the effectiveness of different implementation approaches. For instance, disseminating CPGs in paper copy has little effect, didactic presentations had moderate effect and there is stronger evidence for the effectiveness of peer-leaders, audit and feedback and selfreflection (Grol et al., 2013). However, there continues to be uncertainty as to how to address local barriers and clinician behaviours to sustainably improve practice. One continuing concern is the fear expressed by many clinicians that CPG use will undermine their clinical decision-making autonomy. This can be expressed as disbelief in the nature or strength of the research evidence, or skepticism of the independence of the CPG writing group, or dismissal of CPGs as not relevant to their patient population. In response to this, work has been undertaken in the past few years to address barriers to successful implementation so that end-users can be provided with a

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CPG that already addresses important implementation barriers (Grimmer et al., 2016b). This work is described by Dizon et al. (2016), who proposed the Adopt, Contextualise, Adapt (ACA) approach to CPG implementation.

Clinical Practice Guideline Adoption To adopt a CPG is straightforward across settings with similar environments and similar patient types. For instance, a CPG for the management of hypertension in 2016 in the UK (National Institute for Health and Care Excellence [NICE], 2016) could be simply adopted in similar countries, such as Australia. The adoption process does not require change to any CPG tier (Tier 1 evidence base, Tier 2 clinical expert input or Tier 3 product).

Clinical Practice Guideline Contextualization To adopt an existing CPG into a very different setting (say from an HIC to LMIC) may require additional effort, as the CPG evidence may need additional contextualization to make the recommendations relevant and implementable. This means that the CPG Tier 1 could be adopted (no change), but additional information may be required at Tiers 2 and 3 to ensure that the CPG recommendations reflect local contexts and end-user needs. For example, one recommendation from NICE clinical guideline 68 for stroke (2008, updated March 2017) is that an appropriately trained healthcare professional should assess the swallowing ability of people suffering an acute stroke before being given anything by mouth. In most HIC settings, a speech pathologist, dietician or doctor would perform the swallowing test. However, in many LMICs where there may be few available trained specialist healthcare providers to perform this test, other healthcare professionals (such as nurses) could be trained. See the contextualization approach in the second column in Fig. 10.2. CPG contextualization makes use of Tier 1 – evidence base (unchanged). However Tiers 2 and 3 are layered with additional information to ensure that the recommendation can be implemented in local context situations. Experts (end-users, target audience) are required to discuss how the CPG and the

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recommendations will work in the local context and to provide Tier 2 modification. Successful implementation of the recommendation in local contexts may require locally specific Tier 3 products, such as protocols, algorithms, training documents or checklists. CPG contextualization is an efficient implementation approach that bridges the gap between the parent CPG and its local application, without ‘recreating the wheel’. This approach addresses often insurmountable LMIC challenges of limited time, CPG writing expertise and/or resources.

Clinical Practice Guideline Adaptation To adapt means to change something to suit different conditions or a different purpose. This is where the Dizon ACA model (Dizon et al., 2016) adds subtleties to the ADAPTE model (Amer et al., 2015). Adaptation should occur where an adopted CPG cannot be implemented in its current form in a local environment. A recommended treatment may not be affordable, culturally acceptable, stored safely as is required for drugs or even readily obtained. Thus alternative, locally affordable, available and/or culturally acceptable treatments may be substituted for the recommended care to provide appropriate effective local treatment. Thus an additional evidence base may need to be developed that summarizes additional literature sources about alternative treatment methods. By considering and including local evidence, the CPG recommendation may thus change. For example, the NICE CPG (2015) for diabetes type I recommends rapid-acting insulin analogues be injected before meals. Where there is poor refrigeration, the use of injected insulin may not be a viable local option, and an alternative form of insulin may be required (for instance in tablet form). Adaptation will generally mean a difference between the parent CPG recommendations and locally relevant/acceptable recommendations. This may include different treatments with different forms of administration, where there are considered tradeoffs between treatment effects, side effects, costs, acceptability and shelf-life. In the Project SAGE three-tier CPG model, adaptation entails integration of an additional layer of evidence to Tier 1, which provides the basis for the substitute treatment recommendations. This may then require changes in

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Tiers 2 and 3. See column 3 in Fig. 10.2.

Case Study 10.1

Next-Generation Clinical Practice Guidelines Ann was quite excited about the chance to work with an nongovernment organization in a developing country where she hoped she would be able to make a real difference in people's lives. She soon found that the health problems she was seeing were often different from those she was used to at home. This was because problems that were often quickly dealt with in an industrialized country were left untreated for much longer in a place with few resources, poor transport and a great shortage of accessible health care. Ann turned to available clinical practice guidelines for help and was pleased to find several that seemed relevant but was disappointed to find that most were oriented towards the industrialized societies she had left behind and didn't seem useful when deciding what to do with the patients she was seeing now. However, she did have some access to the Internet and found that a group was trying to adapt some of the guidelines for settings just like hers. She was reassured when she discovered that the group was not only using the rigorous SAGE model but was focussing on the Tier 3 level and looking for low-cost and effective ways that the local population would be able to implement. Ann volunteered to become a contributor to the team and as someone ‘on the ground’ felt that she could make a real difference by testing out some of the proposals and giving feedback as the work developed. She knew that involvement by people like her, who knew just what the local problems were, would give credibility to the adapted guidelines that would eventually be produced and shared.

Reflection Point 5 Ensuring that CPG recommendations can be implemented efficiently in the local environment is a critical part of evidencebased practice uptake and CPG implementation. What factors in

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your own local contexts might affect the implementation of recommendations from CPGs relevant to your field?

Consumer Engagement The term ‘consumers’ refers to CPG end-users. Identifying and addressing the needs of all end-users are essential elements of CPG writing quality (Eccles et al., 2012). Consumers include patients, healthcare professionals, managers, policy-makers and funders. Engaging consumer representatives during the CPG writing process is essential to ensure that the CPG is written in such a way that it resonates with all who use it (Grimmer et al., 2016b). Public consultation for a draft CPG is also a way of ensuring consumer engagement with the CPG before implementation.

Reflection Point 6 CPGs must be written with consideration of patient needs and preferences. How these are built into the CPGs whilst they are being constructed should be transparent and valid (i.e., the information should come from the patients not from healthcare providers who purport to know what patients need). Have you considered how relevant the recommendations in the CPGs are to your patients? Do you use recommendations in the CPGs as a form of communication of the evidence with your patients?

Clinical Practice Guidelines, Clinical Reasoning and Patient Outcomes CPGs are intended to promote better clinical reasoning and health outcomes. Local applicability and relevance are the factors that have the strongest influence on compliance (Eccles et al., 2005). Thus CPGs are more likely to be implemented if produced by locally credible CPG writers and if they do not require significant change in usual activities (Grol et al., 2013). This can be counterproductive if the international best evidence in a CPG is rejected as not being applicable locally and no alternative care

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approaches are substituted. This is where the value of the ACA model becomes obvious (Dizon et al., 2016). CPG-based care considered within the Satterfield et al. (2009) model of evidenceinformed practice provides a framework for decision making by clinicians and enhances the value of clinician–patient interactions and decision-making processes. There is continuing debate about whether CPGs really do improve patient outcomes and decrease costs. These concerns are particularly relevant when CPG recommendations contradict current clinical practice or when significant change in practice behaviours is required to implement guidelines in a sustainable manner (Grol et al., 2013). To measure change that could be attributed to CPG implementation (be it adopted, contextualized or adapted CPGs), strategies must be developed to monitor pre- and postimplementation practices. Audits are usually used to provide this information. Audits use checklists of items that are related to CPG implementation. Accurate and comprehensive record keeping in clinical practice is essential for clinical audits or reviews. In addition to patient details, information such as diagnosis and clinical reasoning prompts, potential risk factors, the recommendations in the CPG, requisite interventions and relevant outcome measures should be recorded on patient notes at regular points in the episode of care. Examples of audit planning and protocols include Gonzalez-Suarez et al. (2015). There are now many standard outcome measures available to evaluate aspects of the effectiveness of management for most health conditions. Thus it is a matter for end-users to identify useful outcome measures and implement them on a regular basis throughout treatment. Health outcome measures should be applied at least twice across an episode of care to demonstrate change in health status (such as on first and last contact with the patient). This would be the minimum number of measures required to demonstrate change. Outcome measures need to reflect issues that are important to clinicians, patients, funders, managers, policymakers and referrer. In some circumstances, they may reflect issues that are important to the family (or carer) and/or to the employer. The most appropriate outcome measured to use to demonstrate the effectiveness of a CPG remains undetermined. Patient Reported Outcome Measures (PROMS) are currently being discussed as a

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way forward. These assist patients to provide direct feedback to clinicians about their health experiences. There are a multitude of published patient health outcome measures that have been developed for research and clinical uses for many conditions and patient types. The iCAHE website provides a manual of freely available patient outcome measures.vi With the recent emergence of health economic evaluations of CPG effectiveness, the availability of quality-of-life measures is increasingly important. Quality-of-life measures are reported as QALYs (Quality-Adjusted Life Years) or DALYs (Disability-Adjusted Life Years) (World Health Organization, 2015). As allied health effectiveness is generally considered in terms of reduced morbidity rather than reduced mortality, evidence of improved quality of life is essential. Allied health clinicians could assist health economic evaluations of CPG effectiveness by routinely measuring patient quality of life.

Reflection Point 7 Good quality recent CPGs provide an invaluable summary source of evidence for clinicians. Recommendations from CPGs could form the ‘research’ element of how you implement EBP in your practice. Do you use CPGs regularly in your practice as a ‘onestop-shop’ for evidence? How do you interpret this evidence into your clinical reasoning, and how do you share this evidence with your patients?

The Future There is a trend to computerize CPGs, particularly Tier 3 recommendations. Although this is not commonplace at present, its use is increasing, especially with recent advances in artificial intelligence. Attempts to use CPGs as interactive decision support systems have been attempted for decades, but with improvements in computer power and the widespread uptake of digital health records, we may now be reaching a tipping point where such support systems can become an everyday reality (Musen et al., 2014). The early systems, which were rule based, made use of socalled ‘inference engines’, and could be queried and made to show

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the procedures by which they made their conclusions. There was hope that such systems could be used to help teach newcomers how to be more rigorous in their clinical thinking by showing them the ways in which the underlying rules had been used to reach a conclusion. Modern systems, however, tend to be based on machine learning and work in ways that the human brain can never hope to emulate. Machine learning requires that the systems be exposed to millions of data records (so-called ‘Big Data’) and look for patterns, sometimes with sophisticated statistical techniques, to query that data. Therefore these systems cannot be used to show humans how they should reason. However, the promise is that these systems will be able to quickly advise clinicians of what they should be paying attention to in a particular case and how to proceed and thus support clinical reasoning. The more adaptable systems should be able to customize their recommendations to local circumstances as they gradually acquire more data and ‘learn’ about the local settings in which they are used. CPGs will be an important data source for developing such systems. The more rigorously a CPG is developed then the more rigorously a computerized decision support system will be able to support the decisions of clinicians in different circumstances.

Reflection Point 8 Computerized decision support systems are a next logical step in the future use of CPGs. The development of increasing computer power, machine learning and the availability of ‘Big Data’ sets mean we may now be at a tipping point where these systems may become an everyday reality. What are some implications of this for you in your practice?

Chapter Summary ■ High-quality CPGs should be based on the bestavailable most recent evidence. ■ They should be constructed using transparent 280

processes that evaluate the volume and quality of available evidence, frame the recommendations in local contexts and support sound clinical reasoning. ■ Healthcare professionals should therefore consider using high-quality, locally relevant CPGs to underpin their practice, as these guidelines can be applied to develop individual care plans for patients. ■ In a world where ‘evidence-based practice’ is a common catchphrase, high-quality CPGs provide health practitioners with a persuasive, costefficient and effective mechanism with which to evaluate and improve practice. ■ CPGs are likely to play a key role in the computerized decision support systems of the future. Reflection Point 9 CPGs have seen rapid change and development in recent years. There are many more of them available. They are now more sophisticated, more rigorous, more adaptable to local settings and more user-friendly than ever. Critical use of CPGs can underpin clinical reasoning that can be justified as evidence-based and in the best interests of individual patients. How have/can CPGs positively influence your own decision making in practice?

References The ADAPTE Collaboration. The ADAPTE process: resource toolkit for guideline adaptation: version 2.0. [Viewed 19 May 2017; Available from:]

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11

Action and Narrative Two Dynamics of Clinical Reasoning Cheryl Mattingly, Maureen Hayes Fleming

CHAPTER AIMS The aims of this chapter are to: ■ look beyond hypothetical deductive reasoning to understand clinical reasoning as action and narrative, ■ focus on ways of understanding clients as people who are making meaning of their illness or injury in the context of their lives, ■ present findings from ethnographic research that illustrates clinical reasoning as action and narrative and ■ invite readers to reflect on their reasoning in the light of the arguments and case study presented.

KEY WORDS

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Two streams of reasoning Active judgement Narrative

Introduction Research in clinical reasoning emerged from the medical problemsolving tradition, which emphasized the hypothetical deductive method. Recently many theorists have argued that this strictly cognitive view is too narrow to encompass the myriad ways in which healthcare professionals devise solutions for clients’ needs. We have found that the desire to conduct effective treatment, especially in the rehabilitation professions, directs the clinician to understand the client as a person who makes meaning of the illness or injury in the context of a life. By emphasizing the social dimension of clinical reasoning, we are highlighting a quality of expert judgement, which is by nature improvisational, flexible and highly attuned to the specifics of the person, the condition and the context. In this chapter, we discuss two streams of reasoning, active judgement and narrative. Working out narrative possibilities and making active judgements are two dynamic processes that intertwine while the clinician carries out the best treatment with and for the individual patient. We further submit that through making and reflecting on these active judgements and narrative possibilities, clinicians develop their own stock of tacit knowledge and enhance their expertise. We draw upon ethnographic research projects we have conducted over the past decade, primarily (but by no means exclusively) among occupational therapists. This chapter is not a report of findings. We refer to these studies in a general way to illustrate and support a conceptualization of clinical reasoning and expertise grounded in the complexities and nuances of everyday practice in the world of rehabilitation.

Action and Judgement Action is the essence of clinical practice. In occupational, physical and speech therapy, the patient must act. Without the patient's

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participation, there is no therapy. One common view of action is that action takes place after one has carefully thought about the problem and its possible resolution. The assumption is that one thinks carefully about the problem, decides what the central issue is, determines the best solution and takes action. This sequence may often be the case, but not always. Some philosophers, particularly phenomenologists, claim that thought and action occur in a rapid dynamic relation to one another, not in a fixed sequence. The word ‘judgement’ is often used to express this dynamic relationship. Buchler (1955), following on the work of John Dewey, C.S. Pierce and others, pointed out that action not only expresses the results of a judgement, it can be a judgement itself. Buchler (1955, p. 11) commented ‘every action is itself a judgement’. Schön (1983) submitted that reflective practitioners act first and judge the results afterward. Architecture students develop their expertise by looking at an area of land and sketching out versions of the structure they envision for that space. This action (sketching) is a way of seeing and a way of thinking. It is an act of both imagination and production, in which an image becomes visible and can be judged. The imagined building comes briefly to life in the form of a drawing. The structure is ‘built’ in imagination, action and judgement long before the backhoe arrives. Between the imaginative eye and the artful hand, the practitioner negotiates the route between the creative image and the concrete restrictions of the size, slope and orientation of the site, using a dynamic process of active judgement. Healthcare practitioners also use imagination and action to make professional judgements about clients’ problems and potential solutions. The patient is a ‘site’ where the best structure must be not constructed but reconstructed. Healthcare practitioners work with persons in crisis, with whom action must be taken immediately. Many judgements are made before, during and after action. In professional work, action and judgement merge. The practitioner often has the advantage of having the patient – the person – as a partner or at least informant in the endeavour. Usually the patient trusts the clinician and is willing to respond to requests for action. The actions that the patient executes give the practitioner a great deal of information. Conversely, the clinician might take action on or with the patient, which provides another source of information.

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The clinician and patient become involved in a coordinated set of actions and interactions that many observers have characterized as a therapeutic dance. Many professional judgements are based on observations and interpretations of patients’ actions. Clinicians want to see if and how a patient can perform an action. The practitioner judges the quality of a motion to make clinical judgements regarding the current level of strength or range of motion and to estimate the possible functional gains the patient may make during treatment. By judging today's action, the clinician can gauge the potential for future functional performance. The patient is often asked to perform specific motions or sets of movements and with frequent numbers of repetitions. Isolated motions, such as elbow flexion or thumb–finger prehension, are requested. Every day the therapist asks for more repetitions, more weight, more concentration and so on. Therapists remind patients that they couldn't do this last week or yesterday and point out what they can do today and where they could be tomorrow or next week. The story of progress towards reconstruction is played out in increasingly better and more functional actions. Therapists want the patient's movements to match the image in the therapist's mind – to meet the perceived potential. Eventually the motions are combined into actions or sets of motions with a motive such as shoulder rotation, elbow extension, wrist stabilization, finger extension and flexion to reach for an object. Later these and other motions and actions are combined so that desired functional activities, such as eating, may be performed. In a sense, it is not the professional who is the therapist but rather the patient and his or her ability to invest in meaningful action. Through this investment, the patient rebuilds the body and reconstructs a sense of self as a person who can function in the world, an actor. Practitioners take many actions while treating their patients. They also gain information from their interpretations of the sensations they receive from the patient, and they learn from their own actions. The therapist tests muscle tone, adjusts the position of finger and thumb in a tenodesis grasp or balances a child in her lap while he works with a toy. In the interest of improving patients’ potential for future action, experts evaluate patients’ actions, guide

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their own actions, make interpretations simultaneously, make rapid judgements and change actions smoothly and rapidly. Action is both a concrete event and a reasoning strategy that mediates the flow of therapy from image to result. Simultaneously, clinicians learn if and how their own actions work as effective treatment strategies. In this way, a wealth of personal/professional expertise is developed.

Tacit Knowledge and Professional Judgement When we conducted our first study (Mattingly and Fleming, 1994) we were confident that we would discover that therapists had a great deal of professional knowledge and skill and had a great stock of tacit knowledge. We did not anticipate the degree to which they were unaware of the amount of knowledge they had. Polanyi (1966, p. 4) coined the term ‘tacit knowledge’ and described it as the stock of professional knowledge that experts possess that is not processed in a focussed cognitive manner but rather lies at a not quite conscious level, where it is accessible through acting, judging or performing. This level of awareness is what Polanyi called ‘the tacit dimension’. It is a type of knowledge that is acquired through experience. Polanyi called it tacit knowledge because experts were able to act on it but could not always verbalize exactly what they were doing or why. He expressed this concisely with the words, ‘we know more than we can tell’. In daily practice, the clinician encounters a new situation, takes action, perhaps several variations of a set of actions, and reflects on them to evaluate whether the action ‘worked’. Was it effective in solving a problem with this particular patient who in some ways was subtly different from the last patient of the same age, gender and diagnosis? Through this action and reflection, the therapist builds a stock of tacit knowledge that becomes increasingly nuanced with further experience. Tacit knowledge has some advantages and disadvantages. It contributes to efficiency. The expert can do what is required, quickly and smoothly in much less time than it takes to explain. Because tacit knowledge is developed in action, it remains accessible to immediately guide action.

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Clinicians often literally act before they think. This is not mindless action; it is an automaticity of expertise that does not have to be processed through the lengthier channels of formal cognition. However, the inability to explain all that one knows can cause others to question the credibility of the professional's knowledge. Occupational therapists in our study had a particular problem with this credibility issue because they had a wealth of practical tacit knowledge and confidence in their clinical skills but did not have a rich language to explain or describe their practice, as do physicians and some other practitioners in the clinical environment. Giving language to some aspects of their practice (Mattingly et al., 1997) gave the therapists a clearer perspective on their practice and a vehicle to examine and advance it. Tacit knowledge works in the immediate situation resulting from its development in the past. It can also work to help a clinician formulate an image of the potential future situation, both as an image and a guide to plan treatment. Following is an example of a clinician whose tacit knowledge was copious and who could also articulate that knowledge given very little prompting.

Case Study 11.1

Narrative Reasoning A Norwegian therapist we know read a transcript of an American therapist's report on her work with a man with a crush injury to his hand. The report was basically a long list of abbreviations about DIP (Distal joint), PIP (Proximal Interphalangeal joint) and other joints and various soft-tissue injuries. This therapist looked up from the notes and sighed. We asked, ‘What is the matter?’ and she said, ‘I can just see it all now. This man is going to get very depressed, lose his job, probably become an alcoholic and his wife will divorce him. He will probably have bad contractures, more surgery, be committed to therapy for a while and cycle back and forth between depression and attempts to get his life and therapy back on track’. We looked at her in astonishment. That was exactly what happened to him. ‘How did you know?’ we asked. She said, ‘I've seen it all before. I have been a hand therapist for several years. As soon as I read the description of his injuries, his hand just

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lit up in my mind. I could just see it. Then his life just rolled along in my mind as well. I knew just how it was going to be. This is a very difficult injury and very devastating to the person’. This experienced therapist knew similar people in the past and was able to envision this person's situation. The strong imagistic quality, to say nothing of the accuracy, of her comments demonstrates more than simple memory. Her capacity to suddenly see this patient in her mind's eye is part of her expertise. The image is a vivid and powerful portrayal of the person's future life. This therapist's ability to create vivid images of a patient's life, to take a minimal description of a hand injury and envision a host of life consequences, including how they might affect the emotions and motives of the patient, also reveals well-developed skills in narrative reasoning.

Narrative Reasoning One might assume that narrative reasoning is related strictly to telling and interpreting stories. However, it has come to be associated with a much broader human capacity. It constitutes a form of meaning making that is pervasive in human activity (Bruner, 1986, 1990, 1996; Carr, 1986; MacIntyre, 1981; Nussbaum, 1990; Ricœur, 1984). In recent years, narrative thinking has been recognized as important in clinical judgement (Frankenberg, 1993; Good, 1994; Hunt, 1994; Hunter, 1991; Mattingly, 1991, 1998a, 1998b, 2004, 2007, 2010; Mattingly and Fleming, 1994). Narrative reasoning is necessary to interpret the actions of others and to respond appropriately to the social context. Bruner (1986, 1996) referred to such reasoning as a capacity to ‘read other minds’, that is, to make accurate inferences about the motives and intentions of others based on their observable behaviour and the social situation in which they act (Mattingly, 2008). When we try to make sense of what another person is up to, we ask, in effect, what story is that person living out? Narrative thinking, as the anthropologist Michael Carrithers (1992, pp. 77–78) observed, ‘allows people to comprehend a complex flow of action and to act appropriately within it … narrative thinking is the very process we use to understand the social life around us’. When occupational therapists reason narratively, clinical

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problems and treatment activities are organized in their minds as an unfolding drama (Mattingly, 1998b, 2010). A cast of characters emerges. Motives are inferred or examined. Narrative reasoning is needed when clinicians want to understand concrete events that cannot be comprehended without relating an inner world of desire and motive to an outer world of observable actions and states of affairs. Narrative reasoning concerns the relationship among motives, actions and consequences as they play out in some specific situation (Bruner, 1986; Dray, 1954; Ricœur, 1980, 1984).

Reflection Point 1 Have you had this experience of your mind ‘lighting up’ about a client's potential clinical and life pathway? Did your prediction come about? What did you learn from this experience? However, attention to the specifics of context is not sufficient to distinguish narrative reasoning from other modes of clinical thinking. As Hunter (1991, p. 28) noted, ‘The individual case is the touchstone of knowledge in medicine’. The hallmark of narrative reasoning is that it utilizes specifics of a very special sort: it involves a search for the precise motives that led to certain key actions and for how those critical actions produced some further set of consequences. Although narrative reasoning is evidently a generic human capacity, it is prone to tremendous misjudgement. As we all know, it is quite easy to misinterpret the motives and intentions of others, especially if they are strangers and come from unfamiliar social or cultural backgrounds. In some cases, and for some practices, interpretive errors are not especially important. One can make a splint, for example, without needing to have tremendous skill in interpreting the meaning of splint wearing for one's client. But one cannot make a good decision about when to give a client a splint or figure out how to get that client to wear it without developing a capacity to assess the beliefs, values and concerns of the client. There are practical reasons why expert rehabilitation professionals, in particular, hone their narrative reasoning skills. The most obvious reason is that effective treatment depends on

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highly motivated patients. As occupational therapists often say, in therapy, patients are not ‘done to’ but are asked to ‘do for themselves’. This ‘active healing’ process means that patients cannot passively yield their bodies to the expert to receive a cure; rather they need to become highly committed participants in the rehabilitation process. This presents a special challenge to the professional: How do I foster a high level of commitment in my patients? This task calls upon narrative reasoning as the practitioner tries to design a treatment approach that will appeal to a particular patient. Occupational therapists refer to this as ‘individualizing treatment’. Narrative reasoning figures centrally in those health professions, such as rehabilitation therapies, where efficacious practice requires developing a strong collaboration with clients. When motives matter, narrative reasoning is inevitable, and poor skills in such reasoning will mean that therapy is likely to fail.

Prospective Stories: Therapy and Life Stories In occupational therapy at least, narrative reasoning is not merely directed at the problem of obtaining the cooperation of a patient during a particular clinical encounter. The therapist's ability to employ narrative reasoning sensitively is essential to another clinical task, helping patients link their past (often a time before illness or disability) to their present and to a future worth pursuing. When therapists ask themselves, ‘Who is this patient?’ they are asking a fundamentally narrative question. They are wondering what might motivate this particular patient in treatment and, beyond that, which treatment activities and goals would be most appealing and useful, given the life this person will likely be living once therapy is completed. Therapists routinely struggle to develop images of their patients as individuals with unique needs and commitments, with singular life stories. ‘Curing’ is rare in the world of rehabilitation, and, in any case, it is not possible to transport a patient back in time to younger and healthier years. Instead, occupational therapists work to connect with patients to judge which treatment goals are most fitting and which treatment

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activities make most sense given the patient's conceptions of what is important in life. Collaboration with patients is so central, it is probably more accurate to speak of the co-construction of treatment goals and activities. In fact, recognizing how complex and important a coconstructive process was, and how crucial it was to developing effective treatment goals, has led one of the authors (Mattingly) to carry out several longitudinal studies that have focussed on patient and especially family caregiver perspectives. This research has precipitated a deepening recognition of how powerful narrative is not only for the reasoning of clinicians but for patients and family members as well. Notably, it plays a crucial role in the fashioning and refashioning of hope over time (Mattingly, 2010, 2014). The power of narrative is an ongoing, largely tacit, reasoning process that guides action and becomes most evident in clinical situations when things break down – when it is difficult for the practitioner to make narrative sense of the clinical encounter or the patient. When practitioners confront patients who are incomprehensible in some significant way, the whole direction of treatment may falter. The tacit narrative reasoning that practitioners carry into clinical encounters is likely to turn into explicit storytelling as they try to discern what is going on and ‘what story they are in’ with a particular client. For instance, a patient may insist that he wants to return to his job, show up to all his clinical appointments faithfully and comply with all the tasks set before him during his therapy hour but never manage to ‘get around’ to doing the exercises he is supposed to be carrying out at home. Without these home exercises, the therapist may explain several times, treatment will not be successful. He will not be able to use his hand. He will not be able to return to work. And yet, nothing helps. Things continue just as before. Perhaps he has been lying or deceiving himself. Perhaps he doesn't want his job back after all. But if he were merely noncompliant and uninterested in returning to work, why does he show up to every appointment so faithfully, even arriving early? Why does he try so hard during therapy time? Such mysteries are common. Therapists become increasingly unclear about how to proceed in their treatment interventions, even when ‘the good’ (outcome) for a patient (say, maximal return of hand function) remains fixed in an abstract sense.

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Narrative reasoning is a guide to a therapist's future actions because it provides images of a possible future for the client. When reasoning narratively, practitioners are trying to assess how to act in particular clinical situations, taking into consideration the motives and desires of themselves, their clients and other relevant actors. The ongoing construction of a narrative framework provides clinicians with historical contexts in which certain actions emerge as the inevitable next steps leading to the most promising future. Although the question of what the good future is for any particular patient may never be explicitly asked, the process of treatment itself is very often a process of exploring and negotiating a vision of the future good. When clinicians assess how they can help patients reshape their situation for the better, this assessment is often informed by a ‘prospective story,’ an imagined future life story for the individual. Thus clinicians contemplate how to situate their therapeutic interventions (a kind of ‘therapeutic present’) in light of a patient's past and some hoped-for vision of what will follow in the future when the patient is discharged. Narrative reasoning is directed to the future in the sense that it involves judgements about how to act to ‘further the plot’ in desirable directions and to subvert, as far as possible, undesirable ones. Although our traditional concept is that stories recount past events, stories in the clinical world are often directed to future possibilities. How are such ‘prospective stories’ communicated to patients or negotiated with them? Generally, it is not by telling the stories in detail. Rather, the stories are sketched through subtle hints or cues or enacted in clinical dramas that prefigure life after therapy. The prospective story is offered, like the architect's sketch, as a possibility, something to be looked at, viewed from different angles, something to make a judgement about. When therapists offer short stories to their patients about what their life will be like ‘in a few weeks’ or ‘when the halo comes off’ or when ‘you are home with the kids’, they are offering images and possibilities of a meaningful future. Therapists hope that a commitment to these narrative images, images that point towards a future life story, will carry the patients through the long, tedious, often painful routines of treatment.

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Active Judgements, Tacit Knowledge and Narrative Images: a Case Story The interplay of actions, judgements, tacit knowledge and narrative image making is dauntingly intricate to describe in the abstract but becomes easily visible when examining concrete instances of practice. The following case story, written by an experienced occupational therapist, illustrates how image, action and narrative come together in expert therapeutic practice.

Case Study 11.2

The Story of Ann 1 Ann was a 26-year-old woman who had given birth and subsequently had a stroke. She was admitted to a rehabilitation hospital with right hemiparesis. When I first met Ann, she was very depressed about being separated from her new baby, and her main fear was that she would not be able to adequately care for the baby on her own. Adding to this fear was the knowledge that her insurance would not cover any in-home services. Her husband was her only family, he worked construction every day and they lived in a trailer park. To go home with the baby, she would need to be very independent. The initial therapy sessions were centred around tone normalization, with an emphasis on mat activities, along with traditional ADL (activities of daily living) training in the mornings. Ann's husband visited daily and usually brought the baby with him. At first, this was extremely frustrating to Ann because she could not hold the baby unless she was sitting down with pillows supporting her right arm. She continued to voice anxiety around the issue of going home and being able to care for the baby. Her husband was also very worried about how this transformation would take place – from Ann as a patient to Ann as wife and mother. I spent a lot of time talking to both Ann and her husband about the necessity of normalizing the tone and improving the movement of the upper extremity as a sort of foundation to the more complex functional skills Ann was so anxious to relearn.

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Eventually it was time to spend the majority of the treatment time on functional skills. The two areas we focussed on were homemaking and child care. The homemaking sessions were fairly routine and traditional in nature. However, it proved to be a bit more difficult to simulate some of the child-care activities. Our first obstacle was to find something that would be like a baby. We settled on borrowing a ‘resusc-a-baby’ from the nursing education department. We used this ‘baby’ for the beginning skills such as feeding and diaper changing. Ann had progressed to a point where she had slight weakness and incoordination in the right arm, and she was walking with a straight cane. The next step was to tackle walking with the baby. We of course practiced with a baby carrier. We also had to prepare for the event of carrying the baby without the ‘carrier’. I wrapped weights about the ‘baby’ to equal the weight of the now 3-month-old infant at home. Ann walked down the hall carrying the ‘baby’, and I would follow behind jostling the ‘baby’ to simulate squirming (we became the talk of the hospital with our daily walks!). Ann was becoming more and more comfortable and confident with these activities, so it was time to make arrangements to have the real baby spend his days in the rehabilitation with his mother. This was not as easy as it might seem. The administration of the hospital was not used to such requests. But with the right cajoling in the right places this was eventually approved. The real baby now replaced ‘resusc-a-baby’ on our daily walks and in the clinic. Although these successes were comforting to Ann and her husband, the fact remained that we were still in a very protective environment. The big question was yet unanswered: Would these skills hold up under the stresses of everyday life – alone – in a trailer for 8 hours daily? Never being one to hold to tradition, I decided to go to administration another time with one more request. I wanted to do a full day ‘home visit’ with Ann and her baby. This too was approved, and 1 week before Ann's scheduled discharge, she and I set out for a rigorous day at the home front. Once there, all did not go smoothly; Ann fell once and practically dropped the baby. She was very anxious and stressed, but we managed to get through the day. We talked and problem solved every little real or perceived difficulty. Both Ann and the baby survived the fall and the ‘almost’

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dropping. When we got back to the hospital, Ann, her husband, the social worker and I sat down and realistically discussed and decided what kind of outside help was a necessity and what Ann could really accomplish in a day. Ann's husband adjusted his schedule, a teenage neighbour was brought in for 2 to 3 hours a day and Ann was able to do the majority of the care for her baby.

1

by Maureen Freda, MA, OTR.

Reflection Point 2 Would you have handled Ann's situation like Maureen? Would your workplace have allowed the flexibility that Maureen achieved to support Ann's transition? What might you have done differently?

Action, Judgement, Narrative and Expertise in Ann's Story In the story, an experienced clinician (Maureen) orchestrated a therapy program for a somewhat unusual patient. Maureen began her story with a typical medical case history approach, but it quickly became evident that the patient's particular life situation shaped Maureen's judgements about how to design treatment. It mattered, for instance, that one of the primary consequences of Ann's stroke was that Ann is fearful about her ability to care for her newborn baby. Maureen also immediately took into account key elements that would be at play in Ann's ‘future story’. Maureen noted the particular situation to which Ann would be returning as a mother unable to afford child care, with no family to turn to except her husband, who worked all day. Maureen judged what actions Ann would need to relearn and selected and invented therapeutic activities based on her perception of the social context and personal goals of Ann and her husband. Maureen was sensitive to the husband's insight about the need for Ann's transformation from patient to wife and mother. She situated her treatment goals within

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the notion of transformation. Her treatment approach developed as a powerful ‘short story’ that assisted in Ann's transformation from fearful patient to confident mother, able to handle even the difficult task of carrying her baby in her arms. Maureen made continual judgements about how to shift treatment from safer and easier tasks to those more closely approximating Ann's ‘real-world’ life situation. In creating this unique treatment story, Maureen relied on her accumulated tacit knowledge culled from years of experience. She drew upon a typical treatment sequence, from building individual motions, to actions, to coordinated functional skills. She clearly had a great deal of tacit knowledge regarding how to help patients build their ADL skills. Although this occupational therapist was able to draw upon a wealth of tacit knowledge, in many ways she faced a singular situation that required her to make judgements specifically tailored to Ann's needs. The symbolic plays a powerful role in this treatment. Maureen saw the need for a substitute or symbolic baby, not just a pretend baby in the form of a pillow. She borrowed a model from another clinical department, and this seemed to do the trick. Maureen moved on with Ann from sedentary baby care activities to the more challenging, complex and risky activity of walking with the baby. She rose to this challenge by developing novel therapeutic activities, such as adding weights and simulating the baby's squirming. These increasingly active qualities of the resusc-a-baby were proxy for the real baby, who then entered the picture as a more viable image. The more realistic the ‘baby's’ actions became, the more Ann became prepared to make the transition from patient to mother. Maureen judged when it is time for the real baby to make an appearance on the rehabilitation floor. Maureen's confidence in her judgements prepared her to make and win the case with administration for the baby to participate in his mother's therapy. The therapy worked. It was clear to everyone that this move beyond conventional practice reaped benefits far greater than would have been obtained had Maureen stuck to conventional exercise and routine ADL activities. Finally, the therapist determined that it was time to take what they had learned and see how they worked in the real-life situation of Ann's home. Here we see that Maureen's perceptions of her own

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judgement and her tacit knowledge differed. She was thoroughly confident that the home visit was the right thing to do. However, she was somewhat less confident regarding the potential success that Ann would have in some of the specific activities of baby care. Ann and Maureen now had enough trust in each other and in the plan to believe that this practice session was well worth any potential risks. Although she didn't say so, we can infer that Maureen was constantly attentive to the small details of the activities that she asked Ann to carry out in the home and set up subtle safety features, including her heightened attention and undoubted physical closeness to mother and child. This confluence of image and action is typical of experienced therapists who are able to see opportunities in the midst of action to gradually or dramatically change their treatment plan in response to particular details of a patient's skills and needs. Notably, this capacity for flexible plan development is central because, as Ann illustrates, a patient's needs and concerns often change over the course of therapy. Maureen, through her sensitivity to this patient and her personal and social context, was able to both speed up and individualize treatment to maximize her ability to act and return Ann to her desired social roles. We have described this treatment process as the creation of a ‘short story’ within the larger life story of the patient, Ann (and, of course, the life stories of her husband and baby as well). Notably, this is a short story that not only connects to Ann's past, as a young woman who has recently given birth, but also to a future, that is, to events and experiences that have not yet taken place. With the careful guiding of treatment activities, the therapist was able to steer Ann towards her hoped-for future, the one where she could independently care for her child, and steer her away from a very undesirable future, one in which she remained depressed and fearful of her capacities to take on such care. The power of any therapeutic short story is its capacity to help patients and their families realize some future story that deeply matters to them. The therapist cannot simply impose this desired future upon Ann, even if it is a future Ann dearly wants. She must look for signals that Ann is ready to move towards it. This requires the therapist's continual judgement about what constitutes the ‘just right challenge’ (Csikszentmihalyi, 1975) for Ann at any moment in

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therapy. Such judgements involve assessing Ann's physical capabilities but also require narrative reasoning, assessing the state of Ann's inner world of emotions, desires and beliefs, as they are expressed in her outward actions and words. Narrative reasoning is also utilized when Maureen helped to create symbolically potent images for Ann, helping her to envision what life will be like with her baby. Maureen created dramatic situations in which Ann could test her abilities and face her fears. This dramatic play allowed Ann to face one of her worst nightmares, as she nearly dropped her child upon returning home for a trial run with Maureen. Notably, these experiences helped Maureen to talk with Ann, her husband and a social worker to make a more realistic plan about how Ann might care for her child upon discharge, including changes in the husband's work schedule and bringing in a neighbourhood babysitter to help out.

Chapter Summary We have found that clinical reasoning is not just one cognitive process and is not limited to the task of making decisions about concrete biological problems. We claim that to be truly therapeutic, clinicians must understand their patients and the ways in which they make meaning in lives that are changed by illness or injury. Two of the ways practitioners perceive patient's perceptions of their past and future lives and orchestrate treatment programs to achieve that future vision have been briefly discussed. These strategies are narrative reasoning and active judgement. These forms of reasoning serve to enlarge clinicians’ stock of tacit knowledge and expand their expertise.

Reflection Point 3 • What have you learned about the place of action and narrative from this chapter? • What have you learned about your own reasoning and practice? Do you have ideas or aims for changing how you reason and act in your practice?

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• How do you think the context or situation of the client and the professional(s) affects reasoning and requires variation in reasoning from one client to another? • Do you think that the interpretation of narrative and action as dimensions of clinical reasoning are applicable across different professions? A suggested task: Write your own therapeutic short story from your experience as a healthcare professional, and reflect on how and what you learn from this activity (a) reveals your past and present practice story and (b) might impact on your future practice story.

References Buchler J. Nature and Judgement. Columbia University Press: New York, NY; 1955. Bruner J. Actual Minds, Possible Worlds. Harvard University Press: Cambridge, MA; 1986. Bruner J. Acts of Meaning. Harvard University Press: Cambridge, MA; 1990. Bruner J. The Culture of Education. Harvard University Press: Cambridge, MA; 1996. Carr D. Time, Narrative, and History. Indiana University Press: Bloomington, IN; 1986. Carrithers MB. Why Humans Have Cultures. Oxford University Press: Oxford; 1992. Csikszentmihalyi M. Beyond Boredom and Anxiety: The Experience of Play in Work and Game. Jossey-Bass: San Francisco, CA; 1975. Dray W. Explanatory narrative in history. Philos. Q.1954;23:15–27. Frankenberg R. Risk: anthropological and epidemiological narratives of prevention. Lindenbaum S, Lock M. Knowledge, Power and Practice: The Anthropology of Everyday Life.

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University of California Press: Berkeley, CA; 1993:219–242. Good B. Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge University Press: New York, NY; 1994. Hunt L. Practicing oncology in provincial Mexico: a narrative analysis. Soc. Sci. Med.1994;38:843–853. Hunter KM. Doctors’ Stories: The Narrative Structure of Medical Knowledge. Princeton University Press: Princeton, NJ; 1991. MacIntyre A. After Virtue: A Study in Moral Theory. University of Notre Dame Press: Notre Dame, IN; 1981. Mattingly C. The narrative nature of clinical reasoning. Am. J. Occup. Ther.1991;45:998–1005. Mattingly C, Fleming MH, Gillette N. Narrative explorations in the tacit dimension: bringing language to clinical practice. Nordiske Udkast. 1997;1:65–77. Mattingly C. Healing Dramas and Clinical Plots: The Narrative Structure of Experience. Cambridge University Press: Cambridge, MA; 1998. Mattingly C. In search of the good: narrative reasoning in clinical practice. Med. Anthropol. Q.1998;12:273–297. Mattingly C. Performance narratives in clinical practice. Hurwitz B, Greenhalgh T, Skultans V. Narrative Research in Health and Illness. Blackwell: London, UK; 2004:73–94. Mattingly C. Acted narratives: from storytelling to emergent dramas. Clandinin DJ. Handbook of Narrative Inquiry: Mapping a Methodology. Sage Publications: Thousand Oaks, CA; 2007:405–425. Mattingly C. Reading minds and telling tales in a cultural borderland. Ethos. 2008;36:181–205.

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Mattingly C. The Paradox of Hope: Journeys Through a Clinical Borderland. University of California Press: Berkeley, CA; 2010. Mattingly C. Moral Laboratories: Family Peril and the Struggle for a Good Life. University of California Press: Berkeley, CA; 2014. Mattingly C, Fleming MH. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. FA Davis: Philadelphia, PA; 1994. Nussbaum M. Love's Knowledge. Oxford University Press: New York, NY; 1990. Polanyi M. The Tacit Dimension. Doubleday: Garden City, NY; 1966. Ricœur P. Narrative time. Mitchell TJ. On Narrative. University of Chicago Press: Chicago, IL; 1980:165– 186. Ricœur P. University of Chicago Press: Chicago, IL; 1984. Time and Narrative. vol. 1. Schön DA. The Reflective Practitioner: How Professionals Think in Action. Basic Books: New York, NY; 1983.

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12

The Language of Clinical Reasoning Stephen Loftus, Joy Higgs

CHAPTER AIMS The aims of this chapter are to: ▪ look at clinical reasoning and its communication through the frame of language, ▪ examine three key devices of language in relation to clinical reasoning: metaphor, narrative and rhetoric and ▪ consider the implications of using these devices on the acts, experience and sense making involved in clinical reasoning.

KEY WORDS Metaphor Narrative Rhetoric

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Introduction In this chapter, we examine the role of language in clinical reasoning. We consider that attention to this aspect of clinical reasoning can help all healthcare professionals come to a deeper understanding of what clinical reasoning is. An awareness of how language works in practice can help novices master the intricacies of clinical reasoning. This awareness can also help teachers develop appropriate pedagogies that can assist students to develop mastery of clinical reasoning. An immediate problem with an approach based on language use is that we need first to dispel a commonly held myth. In the Western world, there is a widespread belief that language is nothing more than the representation of what is already ‘out there’ in the world. This is often called the representation view of language. This view oversimplifies things to the extent that it distorts how we can think about reality. Reality includes the clinical reality of our patients who come to us and expect us to understand their problems and deal with them. A growing number of scholars have come to realize that language is far more complicated than the simple representation view. As Rorty once remarked, ‘The world is out there, but descriptions of the world are not’ (1989, p. 5). Rorty goes on to claim that we make up ways of describing the world that suit particular purposes of ours. For example, the way a clinical psychologist will use language to describe a patient with chronic pain will be quite different from the way a physician will use language to describe the same patient, even though both are being scientific and objective. Representation is just one of the functions of language, and there can be more than one valid way of representing something or someone. However, Wittgenstein (1958) pointed out there are many more functions of language besides representation that are just as important. For example, the following selection of ‘language games’ that Wittgenstein (1958) lists can all be relevant to the activity of clinical reasoning. They include describing the appearance of an object or giving its measurements, reporting an event, speculating about an event or forming and testing a hypothesis. These are language activities that include and go beyond mere representation, and they can all play a part in clinical reasoning. Wittgenstein's work has

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inspired other scholars, such as Gadamer (1989), who have deepened our understanding of how language works. From the work of Gadamer (1989), we realize that language can also be about presentation and bringing things to our awareness in the first place. The ways in which we use language affect how we perceive the world around us, and this is just as true of clinical reasoning (Loftus, 2012). This view of clinical reasoning is interpretive and contrasts with the current and more widespread view that clinical reasoning is, or should be, regarded as a phenomenon of computational logic and symbolic processing, combined with probability mathematics and statistics. This is not to say that the mainstream approaches to clinical reasoning, such as information processing, are wrong but that there are alternative views that can be just as powerful and that can help us both theoretically and practically. This alternative view, based on language use, can sensitize us to important aspects of clinical reasoning that would otherwise be missed. Many have argued, following Aristotle (1983, trans.), that thinking is the internalization of talk we have with others and that in learning to think we learn to have conversations with ourselves (Bakhtin, 1984; Toulmin, 1979; Vygotsky, 1986). According to this argument, we do not first have thoughts, which are then ‘dressed up’ in language. As Vygotsky (1986, p. 218) explained, ‘Thought is not merely expressed in words: it comes into existence through them’. Language serves as a means of controlling what we think and how we communicate. To speak a particular language is to inhabit a particular ‘way of being’ (Wittgenstein, 1958). Language both shapes and limits how we construct our social realities (Higgs et al., 2004). From this viewpoint, language is of primary importance for understanding the nature of thought. The underlying metaphors, the narrative formats and the persuasive ways in which we speak and write all play a role in our thinking and clinical reasoning. According to Vygotsky (1986), we learn at an early age to perceive the world as much through our language as through our eyes. Clinical reasoning is no exception. It is clear that language performs an integrative function. Other symbol systems and cognitive tools can have meaning because they are imbued with language and integrated within it. In the realm of clinical reasoning, there are

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many symbol systems. These can include ECG traces, manual therapy symbols, dental notation, radiographs and MRI scans. Language, in Vygotsky's view, is the ‘tool of tools’ (Cole and Wertsch, 1996) that allows us to bring other symbol systems together into a meaningful whole. There are several ways of looking at language use in clinical reasoning. In this chapter, we focus on a few of the better known. One example of language use is metaphor.

Metaphor Lakoff and Johnson (1980) claimed that thought and language are fundamentally metaphorical. Metaphor is not simply an embellishment of language exploited by writers and poets. It can be argued that language and thought are intensely and inherently metaphorical, and, because of this, metaphor use goes largely unnoticed as it is so completely natural to us. Metaphor is therefore a major means for constituting reality. The implication of this view is that we do not perceive reality and then separately interpret it and give it meaning. Once we acquire language, we perceive reality immediately through the lens of language. As Foss (2009) observed: Metaphor is a basic way by which the process of using symbols to construct reality occurs. It serves as a structuring principle, focusing on particular aspects of a phenomenon and hiding others; thus, each metaphor produces a different description of the ‘same’ reality (p. 268). In recent years, there has been a growing recognition of the extent to which metaphor underlies scientific and medical practice and shapes the ways in which both healthcare professionals and their patients conceptualize their health problems and how they can be addressed (e.g., Reisfield and Wilson, 2004). One example of how different metaphors have shaped thinking in health care comes from the literature on the HIV/AIDS issue. See Case Studies 12.1 and 12.2.

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Case Study 12.1

Metaphors in the Area of HIV/AIDS Sherwin (2001) looked at the metaphors used by various interest groups in the HIV/AIDS issue, revealing how certain metaphors favour distinctive ways of thinking and showing that there are ethical implications arising from using particular metaphors. Sherwin argued that at one time epidemiologists favoured the metaphor ‘AIDS is a lifestyle disease’. This encouraged them to pursue certain sorts of scientific practices such as looking for a multifactorial disease model, attending to some social conditions such as sexual orientation and patterns of drug use. However, the metaphor discouraged other lines of inquiry such as investigating homosexual behaviour in men who considered themselves to be heterosexual. The epidemiologists also resisted for some time the suggestion that a single causal virus might be responsible for AIDS. High-risk groups therefore became the focus of attention, instead of high-risk behaviour. Sherwin's opinion was that the underlying metaphor discouraged the epidemiologists from considering other ways of thinking about AIDS, and because they were so dominant in the field there was some delay before the medical establishment eventually accepted the viral cause of AIDS. The ethical implication is that the metaphors used might have resulted in unnecessary suffering of AIDS patients and infection of people who might otherwise have been alerted earlier to the dangers they faced. Another way of representing this is that the different metaphors encouraged healthcare professionals to tell particular stories/narratives about AIDS.

Case Study 12.2

Metaphors in Pain Management Metaphors used in pain management can show how metaphor use affects clinical reasoning. A key metaphor underlying the biomedical model is ‘the body is a machine’. This metaphor shapes the way many healthcare professionals think and is so widespread that many patients in Western societies also use this metaphor when thinking about their bodily problems (Hodgkin, 1985). The

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implication of this metaphor is that we can always, in principle at least, repair a broken machine. In acute care, this metaphor could be appropriate. For example, a patient with a toothache can go to a dentist who can provide a technical ‘fix’ in the form of fillings, root canal treatments or extractions. From this viewpoint, the body's technical problem is repaired, and the patient can go about his or her business. However, the metaphor frequently falls down in the chronic situation where repeated attempts at repair fail, resulting in frustration and disappointment for both patients and healthcare professionals. Often such patients are ‘discarded’ by the system as failed patients (Alder, 2003). This metaphor can also confuse healthcare professionals when they try to make sense of phenomena such as the placebo effect. The placebo effect occurs when a beneficial effect is produced by a mechanism that is known to be technically ineffective. A wellknown placebo example is pain relief from pills with no active ingredient. For healthcare professionals who restrict themselves to thinking with ‘the body is a machine’ metaphor, this makes little sense (Loftus, 2011). It is as if we took a malfunctioning car to a mechanic who used tools that do not work, and we then discover that the ineffective tools have repaired the problem. A way to understand what is happening in the placebo effect is to use different metaphors to conceptualize what is going on. Perhaps a more useful metaphor here would be ‘pain is interpretation’. It is now widely accepted that pain is a subjective interpretation and that restricting ourselves to mechanistic thinking misses this interpretive element. Moerman (2002) spoke of the meaning effect. Placebos can work because of what they subjectively mean to us as people. Purely technical thinking prevents us from seeing that what experience means to us can profoundly alter how we perceive experiences like pain. This takes us back to the point made by Foss (2009) that metaphors can emphasize some aspects of a phenomenon but at the expense of hiding other aspects. ‘The body is a machine’ metaphor hides away the people who come to us as patients and seduces us into thinking of them only as machines to be mended. Metaphors shape the way we think about health care in general terms, but they also shape the way healthcare professionals think through the individual problems of patients as they reason their

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way towards a diagnosis and treatment plan.

Reflection Point 1 What metaphors underpin clinical reasoning in your health profession? How are these metaphors helpful? What do they ignore or miss?

New Metaphors in Clinical Reasoning In recent years, there have been debates about other ways of reconceptualizing patient experiences; these debates include consideration of new metaphors that might be used to enrich our understanding of symptoms so that we can manage them better (Loftus, 2011). For example, pain has traditionally been regarded as a symptom, but there have been calls to reconceptualize pain as a disease entity in its own right (Siddall and Cousins, 2004). This debate is essentially about two metaphors we can use to think about pain – the older metaphor that represents pain as a symptom versus the newer metaphor that represents pain as a disease. Changing metaphors like this provides a ‘reframing’ in which the new metaphor offers a different way for interpreting and understanding patients and the problems they have. Conventionally, pathologies are seen as causes that produce effects that are called symptoms, such as pain. Following ‘the body is a machine’ metaphor, healthcare professionals have been taught that it is far more important to deal with the cause of a mechanistic problem rather than the effects. Once the root cause of a mechanistic problem is dealt with, the effects tend to disappear. Because pain is seen as a ‘mere’ effect, it is often ignored while healthcare professionals focus their attention on finding and dealing with the causal pathology. As Siddall and Cousins (2004) point out, the result is that pain management is still very poor in the Western world. By trying to depict pain as a disease entity (a cause-effect mechanism in its own right), they are trying to reconceptualize pain as something that is more likely to attract the attention of healthcare professionals and be dealt with much more effectively. A similar motive underlies the attempt to have pain recognized

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as the fifth vital sign, along with heart rate, respiratory rate, temperature and blood pressure (Berdine, 2002). There is frequently a requirement to observe and record vital signs in many hospital patients. If pain was included as a vital sign, then healthcare professionals would be required to routinely assess pain and document it. Presumably, pain management would then receive much more attention. Claiming that pain is a vital sign is a metaphorical switch that seeks to change thinking in an attempt to improve outcomes for patients. Much of the debate in the literature has been about which metaphors are closer to the ‘truth’. In a sense, this debate is irrelevant. Metaphors cannot be true or false, but they can be more or less useful. What really matters in these debates is which metaphors are more useful and for whom. The overriding question is – what works for patients? How can we improve our clinical reasoning so that we get better results for patients? These questions emphasize the difference between medical science and medical practice. Medical practice is based on medical science, but the two are not identical. Whereas medical science, like all science, is concerned with the ‘truth’, medical practice is concerned with what works for patients. It is worth remembering the words of Rorty: Human beings, like computers, dogs, and works of art, can be described in lots of different ways, depending on what you want to do with them – take them apart for repairs, reeducate them, play with them, admire them, and so on for a long list of alternative purposes. None of these descriptions is closer to what human beings really are than any of the others. Descriptions are tools invented for particular purposes, not attempts to describe things as they are in themselves, apart from any such purposes (Rorty, 1998, p. 28).

Reflection Point 2 As we have seen, different metaphors provide the foundations for different descriptions. What matters is how well the descriptions (and their underlying metaphors) serve the purposes for which

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they are used. If the purpose is encouraging healthcare professionals to manage pain better, then describing pain as a disease or vital sign may well serve the purpose better than thinking of pain as a nerve signal or symptom. In this sense, the truth is irrelevant. The various descriptions healthcare professionals make of patients' problems are often in the form of narratives.

Narrative A major aspect of clinical reasoning is the construction of a narrative about a patient within the conceptual framework of a health profession and the specific context of the patient and the workplace. There is a growing realization of the importance of narrative in therapeutic encounters (e.g., Charon et al., 2017). The construction of a clinical narrative occurs in a manner that not only takes account of the past and present but also suggests the narrative trajectory that the patient's story might follow in the future, predisposing towards particular decisions about management. Such narratives can be diagnostic, prognostic and therapeutic. See Case Studies 12.3 and 12.4.

Case Study 12.3

Patient Narrative in Dentistry A patient in her late teens presents to a dentist with a story of toothache at the back of the mouth that comes and goes spontaneously, is becoming more frequent and lasts longer each time it occurs. The dentist assesses the patient and reinterprets the patient's story in the professional discourse of dentistry and surgery. The reinterpreted narrative might then become a story of impacted wisdom teeth. This new story can be substantiated with scientific evidence in the form of radiographs that show the offending teeth in their impacted position. The scientific evidence is given its meaning and importance by being integrated into the story of this patient's impacted wisdom teeth (Loftus and Greenhalgh, 2010). A major advantage of this professional reinterpretation is that the dentist's version has a narrative

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trajectory into the future. This narrative trajectory gives meaning to the whole episode.

Case Study 12.4

Patient Narrative in Rehabilitation Sometimes the meaning given by this narrative trajectory can be crucial. One of the best examples of this comes from the work of a rehabilitation centre in which a patient recovering from a head injury is introduced to the centre by an occupational therapist and shown where the various therapeutic activities will take place (Mattingly, 1994). The therapeutic activities, however, are not introduced simply as activities. As Mattingly points out, there is a deliberate effort by the occupational therapist to outline to the patient how the activities can be used so that he can eventually leave and move on to a life beyond therapy. Mattingly's point is that without this narrative trajectory, there is a risk that the patient would find the therapy meaningless and might not collaborate with treatment. This is another situation in which the meaning of the clinical situation can have a dramatic effect on what happens and how well patients do. It is also clear from this example that the healthcare professional has to persuade the patient to accept this narrative trajectory.

Reflection Point 3 What kinds of stories does your health profession use? How do these stories help your clinical reasoning?

Rhetoric Rhetoric is the art of persuasive speaking or writing. A great deal of clinical reasoning is concerned with persuasion. Healthcare professionals need to persuade other people, such as funders, patients and their families and other clinicians, that a particular assessment and proposed course of action are both legitimate and sound. Above all, healthcare professionals have to persuade

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themselves. One medical student reflected on the importance of this issue when discussing how to cope with an inadequate clinical report from a colleague: It's just being able to say what you find, and be able to say that … this person is in very dire straits. It's not making up stuff, but it's being able to present it in a convincing and competent manner that they [senior doctors] can say, ‘All right, this requires my attention’ (Loftus, 2006, p. 190). Another medical student described the feedback he received after reporting on a complex patient assessment conducted under examination conditions. The setting was an examination, and the two senior clinicians hearing the student's report knew exactly what was wrong with the patient, along with all the comorbidities and how they complicated management. They told the student: ‘you’re very organized but you’ve got to get to the point now and tell us to where you want to go. You should be a bit more specific' (Loftus, 2006, p. 154). Reflecting on this exchange, the student realized that the examiners wanted him to be more persuasive and lead them more convincingly to a definitive diagnosis and course of action. They wanted to hear a more persuasive story that worked towards a clear goal at the end. This is an important aspect of medical practice. In many countries, senior doctors cannot physically see all the patients nominally in their care. They rely on junior doctors doing assessments and giving reports. The senior doctors want to be able to make decisions based on these reports, and therefore they depend on junior doctors persuading them that the assessment has been done thoroughly and can be relied on. Senior doctors themselves confirm this insight. The trainees [junior doctors] need to learn that [they have to] cut down the amount of information to a manageable summary for your colleagues … and for yourself because … at the end of the day … you have to be able to isolate them [important findings] and make a decision on them (Loftus, 2006, p. 193). This ability is both a narrative and a rhetorical skill. In

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constructing a clinical report, a healthcare professional is justifying a claim about a patient. The justification is supported by arguments that depend on the context of that patient and that will stand up to reasonable criticism. As Perelman (1982, p. 162) argued, ‘As soon as a communication tries to influence one or more persons, to orient thinking … to guide their actions, it belongs to the realm of rhetoric’. There is frequently uncertainty in clinical reasoning, uncertainty that is associated not with self-doubt or the inability to make sound decisions but rather with the ‘greyness’ or complexity of practice situations, the variability of patient's or client's needs and the presence in many situations of various acceptable solutions (e.g., management strategies). And, when there is uncertainty, judgements must be made in light of all the information available for that case. This is not done mathematically or statistically but persuasively and argumentatively. This is the essence of rhetoric and of pragmatism – not the abandonment of logic or professional judgement but the incorporation of these into the intensely practical and human world of health care. Consider the use of language devices in reasoning using Case Study 12.5.

Case Study 12.5

Joe's Story Joe was getting used to working as a physiotherapist in an interprofessional pain management clinic. He wrote quickly as he summarized the assessment of his last patient. Although the assessment had taken 1 hour and the patient had lots of problems, he knew that he would only get about 1 minute to report on this patient at the case conference with the other healthcare professionals who had also seen the patient that day. He was mastering the art of confining his report to the key findings that the rest of the team would find useful. He realized that there would be some overlap with the doctor's report, and he would need to avoid repetition. On reflection, he realized that the rest of the team questioned him now far less than they did when he first started work there. They were clearly learning to trust his judgement.

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One of his key findings was that the patient strongly believed that her ongoing pain meant that there was continuing injury. This was why the patient was so reluctant to move. If their management was to be successful, it would need to include a strong educational element in the treatment plan. They would need to persuade the patient to think about the pain differently. He realized just how much his own thinking had changed through working in the clinic. Most of the therapy they offered was designed to get patients to move away from thinking of their bodies as broken machines and instead to work on ways of managing their chronic pain. The underlying message of the therapy was that ‘life is a journey’, and they could provide patients with the means of moving on with that life, despite chronic pain.

Reflection Point 4 Does Joe's story reflect your experience of framing and presenting your reasoning? What sort of language devices do you use to make sense of your reasoning and communicate it?

Chapter Summary Using language as a theoretical lens allows us to see clinical reasoning in a very different way compared with the mainstream views such as hypothetico-deductive reasoning, information processing or evidence-based practice. This is not to deny the importance of the mainstream views but to point out that we can integrate them into a more coherent, and more cohesive, whole by seeing the role they play in the overall language game of clinical reasoning. The information from the evidence base, like all relevant information about a patient, has to be integrated into the narratives we construct about our patients, and this is done persuasively.

Reflection Point 5 How can we use the ideas in this chapter to improve the teaching of clinical reasoning to students?

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References Alder S. Beyond the Restitution Narrative. [PhD thesis] University of Western Sydney: Sydney, NSW; 2003. Aristotle. (trans.) Aristotle's Physics i, ii. [trans. W. Charlton] Oxford University Press: Oxford, UK; 1983 [(originally published c. 400 bc)]. Bakhtin M. Problems of Dostoevsky's Poetics. University of Minnesota Press: Minneapolis, MN; 1984. Berdine HJ. The fifth vital sign: cornerstone of a new pain management strategy. Dis. Manage. Health Out.2002;10:155–165. Charon R, DasGupta S, Hermann N, et al. The Principles and Practice of Narrative Medicine. Oxford University Press: New York, NY; 2017. Cole M, Wertsch JV. Beyond the social-individual antimony in discussions of Piaget and Vygotsky. Hum. Devel.1996;39:250–256. Foss SK. Rhetorical Criticism: Exploration and Practice. fourth ed. Waveland Press: Long Grove, IL; 2009. Gadamer HG. Truth and Method. second ed. Continuum: New York, NY; 1989. Higgs J, Andresen L, Fish D. Practice knowledge: its nature, sources and contexts. Higgs J, Richardson B, Abrandt Dahlgren M. Developing Practice Knowledge for Health Professionals. ButterworthHeinemann: Edinburgh; 2004:51–69. Hodgkin P. Medicine is war: and other medical metaphors. Br. Med. J.1985;291:1820–1821. Lakoff G, Johnson M. Metaphors We Live By. University of Chicago Press: Chicago, IL; 1980. Loftus S. Language in Clinical Reasoning: Learning and Using the Language of Collective Clinical Decision Making. [PhD thesis] The University of Sydney: Sydney, NSW; 2006 [Available from]

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http://ses.library.usyd.edu.au/handle/2123/1165. Loftus S. Pain and its metaphors: a dialogical approach. J. Med. Human.2011;32:213–230. Loftus S. Rethinking clinical reasoning: time for a dialogical turn. Med. Educ.2012;46:1174–1178. Loftus S, Greenhalgh T. Towards a narrative mode of practice. Higgs J, Fish D, Goulter I, et al. Education for Future Practice. Sense Publishers: Rotterdam, The Netherlands; 2010:85–94. Mattingly C. The concept of therapeutic ‘emplotment’. Soc. Sci. Med.1994;38:811–822. Moerman D. Meaning, Medicine and the Placebo Effect. Cambridge University Press: Cambridge, UK; 2002. Perelman C. The Realm of Rhetoric. [trans. W. Kluback] Notre Dame University Press: Notre Dame, IN; 1982. Reisfield GM, Wilson GR. Use of metaphor in the discourse on cancer. J. Clin. Oncol.2004;22:4024– 4027. Rorty R. Contingency, Irony and Solidarity. Cambridge University Press: Cambridge, UK; 1989. Rorty R. Against unity. Wilson Q.1998;22:28–39. Sherwin S. Feminist ethics and the metaphor of AIDS. J. Med. Philos.2001;26:343–364. Siddall P, Cousins M. Persistent pain as a disease entity: implications for clinical management. Anesth. Analges.2004;99:510–520. Toulmin S. The inwardness of mental life. Crit. Inq.1979;6:1–16. Vygotsky LS. Thought and Language. [trans. A. Kozulin] MIT Press: Cambridge, MA; 1986 [(originally published 1962)]. Wittgenstein L. Philosophical Investigations. [trans. GEM Anscombe] third ed. Prentice Hall: Upper Saddle River, NJ; 1958 [(originally published

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1953)].

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13

Evidence-Based Practice and Clinical Reasoning In Tension, Tandem or Two Sides of the Same Coin? Aliki Thomas, Meredith Young

CHAPTER AIMS The aims of this chapter are to: ▪ explore relationships and differences between clinical reasoning and evidence-based practice and ▪ consider the implications of adopting different approaches to understanding these relationships.

KEY WORDS 322

Evidence-based practice Clinical reasoning

ABBREVIATIONS/ACRONYMS EBP Evidence-based practice EBM Evidence-based medicine

Introduction Evidence-based medicine (EBM) and clinical reasoning are distinct but interrelated concepts and have evolved in relatively parallel literatures. Several definitions of EBM have emerged over the years sparked largely by differences in disciplinary and professional perspectives. One of the earliest and most commonly used definitions of EBM described ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett et al., 1996, p. 71). In parallel to an evolution of the concept of EBM, we have also seen an evolution in language surrounding the concept – with professions such as nursing and rehabilitation adopting terms such as evidence-based practice (EBP) (Bennett and Bennett, 2000) or evidence-based health care (EBHC) (Hammell, 2001) to reflect a broader application of this concept across health professions. For the purposes of this chapter, we will use the term EBP to reflect the multiple dimensions of the concept. The formalized steps involved in the EBP process include 1) posing a clinical question, 2) searching the literature, 3) appraising the literature, 4) considering research evidence in clinical decision making and 5) reviewing the procedure and outcome of the EBP process (Sackett et al., 1996; Sackett et al., 2000). See Fig. 13.1.

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FIG. 13.1 What is evidence-based medicine? (Adapted from Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, B.R., Richardson, S.W., 1996. Evidence based medicine: what it is and what it isn't. BMJ 312, 71–72.)

Conceptualizations and ensuing refinements of the concept of EBP have since expanded to include consideration for the sociohistorical, political, professional, economic and institutional contexts (Banningan and Moores, 2009) (Fig. 13.2). Further considerations can include explicit integration of the mandate of the healthcare organization, a role for community involvement and potential limitations imposed by organizational and resource constraints. This apparent evolution in what EBP ‘is’ or represents is in large part a result of decades of debate about the merits of the EBP approach to decision making (Dijkers et al., 2012; Greenhalgh et al., 2015). A number of debates have been centralized around disagreements regarding the meaning and significance of ‘evidence’ and the implications associated with clinical decision making ‘based’ on evidence in contrast to clinical decisions ‘informed by’ evidence (Wyer and Silva, 2009).

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FIG. 13.2 Model of professional thinking. (From Banningan, K., Moores, A., 2009. A model of professional thinking: integrating reflective practice and evidence based practice. Can. J. Occup. Ther. 76, 342–350, with permission.)

The literature has been rich with discussions regarding the value of EBP and its corresponding epistemological foundations (Bennett et al., 2003; Djulbegovic et al., 2009; Hammell, 2001). It is beyond the scope of this chapter to delve into, or preferentially support, one particular viewpoint over another; sophisticated debates have already taken place across many other disciplines and professions. The disputes and deliberations notwithstanding, EBP is regarded as an integral and necessary component of clinical decision making (Sackett et al., 2000; Salmond, 2013). Clinical reasoning carries its own set of definitional challenges. There is an abundance of literature on clinical reasoning across disciplines, professions and methodological traditions, and clinical reasoning is considered core to the practice of health practitioners (Higgs et al., 2008; Schell, 2009). Though not as overtly contentious as the definition of EBP, there is little agreement about what is specifically meant by the term ‘clinical reasoning’ or what it entails (Durning et al., 2013). Considered as the backbone of professional practice (Higgs et al., 2008; Mattingly, 1991), clinical reasoning has been defined as an outcome, a means to an end and a process that results in diagnosis and treatment (Eva, 2005).

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Reflection Point 1 To you, is clinical reasoning an outcome, a process, a means to an end or something else? Clinical reasoning and EBP have, for the most part, existed in parallel bodies of literature attempting to describe the practice of health professionals and suggest areas of improvement. Although both literatures house independent debates regarding how a clinician should ‘best solve’ a clinical case and discuss areas for better patient outcomes and how best to support clinical decisions, little work has engaged directly with both concepts to identify areas of similarity or overlap. With these historically siloed areas of work, important questions have remained underaddressed. Here, we propose to delve into the potential relationships between EBP and clinical reasoning. We will engage with the conceptual arguments that one is a precursor, component, or vehicle for the other. The purpose of this chapter is not to provide a ‘right’ answer to these questions but, rather, to explore these distinctions. In this chapter, we will summarize appropriate frameworks or theories relevant to the relationship between EBP and clinical reasoning, to consider potential unintended consequences of adopting a specific stance about their relationship, to discuss how these different interplays between EBP and clinical reasoning might manifest in clinical practice and to identify areas rich for future research. The chapter is organized in three sections, each representing a different stance regarding the relationship between clinical reasoning and EBP. Within each section, we pose a series of questions for reflection. The first section explores EBP as a contributor to the process of clinical reasoning. Drawing from the literature on the theoretical and philosophical tenets of EBP, we present circumstances in which EBP could be considered a contributor to the overarching process of clinical reasoning and potential downstream consequences of this conceptualization. Then we discuss implications for healthcare professionals who may be situated within this perspective and present unanswered questions for reflection and future research. In the second section, we explore the premise that EBP is the way

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in which clinical reasoning unfolds – or should unfold. In this section, we draw primarily from the clinical reasoning literature to highlight how this relationship may or may not hold true depending on the chosen theoretical perspective informing clinical reasoning. We conclude the section with potential downstream consequences, implications for practitioners and future areas for research. The final section considers the proposition that EBP and clinical reasoning are different words/frames for the ‘same thing’. We begin this section by presenting the multiple possible conceptualizations of evidence and propose that ‘evidence’ is more than knowledge generated through empirical research. As with the first two sections, we explore potential downstream consequences of this approach and what this may mean for a practicing health professional with a focus on issues of professional autonomy and discuss avenues for future research.

Section 1: Evidence-Based Practice Is a Contributor to Clinical Reasoning Clinical reasoning has been proposed to encompass all cognitive and environmental factors that lead to, support and shape a final decision – whether about a diagnosis or treatment plan (Durning et al., 2013). If clinical reasoning reflects an overarching set of approaches or processes that are a ‘means to an end’, then it stands to reason that EBP could be considered within the ‘laundry list’ of approaches or processes that lead to, support or shape a final clinical decision. As mentioned in the introduction to this chapter, there is an abundance of literature that converges on the notion that EBP is an approach to clinical decision making. It is considered an approach, not the only approach (Haynes, 2002). Whether one is referring to Sackett's earlier definition of EBP (Sackett et al., 1996) or to the one represented in a recently revised transdisciplinary model by Banningan and Moores (2009), EBP emphasizes the interaction of three main factors: the best available evidence, input from the patient regarding his or her care and the clinician's experience and professional expertise (Craik and Rappolt, 2003; Thomas and Law, 2013). Fig. 13.1 is a traditional representation of EBP, and in this

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Venn diagram, the clinical decision making lies in the middle – it is a result of the contribution of, and the interactions between, its three main components. There is no implied weight or size associated with each component, leaving one to presume that a clinical decision is the result of equal interdependent contributions from each of the three components. Though this equitable balance of sources of information may be the case in some clinical situations, there is a paucity of research to substantiate such an interpretation.

Reflection Point 2 How does this interpretation align with your view of the relationship between EBP and clinical reasoning? The notion of balancing multiple sources of information (YousefiNooraie et al., 2007) puts the onus and focus on the reasoning of the individual clinician. Much of the debate surrounding the EBP movement has been attributed to the implicit value judgement that an evidence-based approach to any clinical decision is only as good as the clinician who is responsible for balancing the multiple sources of evidence – of evaluating the available scientific evidence, considering it in light of the patient's personal and unique circumstances and balancing the unique expertise of the clinician. Haynes et al. (2002) suggested that ‘evidence does not make decisions, people do’. If one accepts this premise, then it follows that most, if not all, clinicians who find themselves in a situation of having to deliberately and consciously combine formal research evidence, patient preferences and a knowledge base derived from their own experience are engaging in a particular form of clinical reasoning. The use of and reliance on information are predominantly for the end goal of making a clinical decision. Combining various sources of data, making sense of the evidence and considering the patient's unique situation and goals for treatment would require that the clinician engage in clinical reasoning. In the absence of a reasoning process, it would seem reasonable to suggest that the various knowledge sources are discrete pieces of information without a unifying purpose and with

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limited meaning. If one accepts that clinical reasoning is a large collection of approaches and strategies used to reach a clinical decision, then it follows that EBP represents one approach to reaching that decision and is one strategy among other strategies or approaches such as, for example, nonanalytic reasoning (Kulatunga-Moruzi et al., 2001), reliance on heuristics (Kahneman, 2011), mobilization of illness scripts (Charlin et al., 2007) and reflective practice (Kinsella, 2007). Studies of experienced clinicians in rehabilitation contexts who embrace and apply EBP have shown that the patient is at the centre of all decisions (Craik and Rappolt, 2006; McCluskey et al., 2008; Thomas and Law, 2013; Thomas et al., 2012). Although the available scientific evidence is used to inform assessment choices and treatment interventions, findings from these studies suggest that the reasoning involved in the decision-making process is largely influenced by a deep desire and motivation to improve patient outcomes (Thomas et al., 2012). The scientific evidence in these circumstances is one ‘tool’ in a clinician's repertoire. If EBP is one approach to clinical reasoning, and formal scientific evidence is one component of that process, it follows that other component ‘pieces’ such as clinical experience, patients' wishes, organizational mandates and professional culture are likewise significant and valued contributors to the reasoning process. In this conceptualization of evidence as a contributor, these components are equally valued, recognized and rewarded. If we adopt the view the EBP is one among many means by which to reach a clinical decision, then several downstream consequences may become apparent (Box 13.1).

Box 13.1

Downstream Consequences of the View That EBP Is a Contributor to the Process of Clinical Reasoning ▪ EBP is one among many, not ‘first among equals’. Therefore it isn't the ‘best’ way of reasoning, only one of many approaches

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to reasoning. ▪ If EBP isn't ‘the best kind’ of reasoning, but rather only one kind of reasoning, how do we decide what the ‘best’ way to treat someone is? How do we develop decision algorithms or practice guidelines for best practice if EBP is just ‘one way’ of reasoning? ▪ EBP may undervalue ‘evidence’ that is not generated through empirical research. If EBP is only one potential approach to reasoning, what would the downstream consequences be for health professions education? ▪ The perspective that EBP is one contributor, or potential approach to clinical reasoning, may be both empowering and validating for clinicians. It supports the notion that there is a multiplicity of information and knowledge sources, factors that influence the reasoning process and different ‘means to an end’. This perspective allows for recognition of the value of professional experience and clinicians' ability to make thoughtful decisions, some informed by best available scientific evidence, others not. Further, this perspective aligns well with what it means to be a healthcare professional. Healthcare professionals have the autonomy to exercise judgement about how they make decisions (Cruess and Cruess, 2008), what information sources they draw from to come to those decisions and under what circumstances they will resort to scientific evidence to support a clinical decision. ▪ Finally, this perspective suggests that complex health issues experienced by human beings with unique backgrounds and lived experiences cannot ultimately be reduced to problems that can and must be solved with the application of the best available scientific evidence.

Reflection Point 3 What would happen to the role of the medical scholar described in the CanMeds framework (Frank et al., 2015, p. 24) as ‘physicians who demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship’ or the medical expert

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described ‘as a physician who provides high-quality, safe, patientcentred care, physicians draw upon an evolving body of knowledge, their clinical skills, and their professional values’ given this perspective? Similarly, in another health profession – occupational therapy – the scholarly practitioners are defined as individuals who ‘bases their work on the best evidence from research, best practices, and experiential knowledge. Practitioners evaluate the effectiveness, efficiency, and cost-effectiveness of client services and programs. Occupational therapists engage in a lifelong pursuit to continuously maintain and build personal expertise. A commitment is demonstrated to facilitate learning and contribute to the creation, dissemination, application, and translation of knowledge’ (Canadian Association of Occupational Therapists, 2012, p. 3). If we accept that EBP is one way, not the way, of engaging in clinical reasoning, how do we simultaneously encourage and promote the development of the scholarly practitioner?

Areas for Future Research Accepting that EBP is as a contributor to the process of clinical reasoning, we are left with questions that we hope will stimulate discussion among our colleagues in the scholarly and clinical communities and present these as suggestion of areas for future research. 1. If EBP is one among many strategies, we need to better understand how evidence is used and/or mobilized during the decision-making process. It is possible that the process of evoking the evidentiary base for a clinical decision has become automatic. If so, a clinician would not necessarily be engaging in the traditional evidence-based approach to practice with its corresponding five steps. In other words, EBP would not manifest as typically represented in the EBP literature. Is the practitioner still engaging in EBP? Or is he or she engaging in nonanalytic reasoning? What are the implications for education and continuing profession development – both in terms of process and practice

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change? 2. If we consider that ‘using evidence’ can be done automatically, this may necessitate some conceptual reframing of the traditional understanding of EBP and the coordination with other clinical reasoning concepts such as nonanalytic reasoning. 3. What is the relative contribution of the scientific evidence to clinical reasoning, regardless of nomenclature? Some work has suggested the role of basic science in reasoning through novel problems (Woods et al., 2006); however, little is known regarding the extent to which clinicians evoke the evidence in a conscious or a more automatized process during decision making. In what kind of clinical situations would conscious reliance on scientific evidence be most effective? How should this be communicated to learners and novice clinicians who, for the most part, have been trained in an era of very formalized and stepwise EBP? 4. Knowledge translation researchers are tasked with bridging research to practice gaps to ensure the most recent relevant evidence is being utilized to make clinical decisions (Graham et al., 2006). If EBP is viewed as a contributor or one of many possible approaches or strategies for clinical reasoning, what does this mean for the practice of and research on knowledge translation, which predominantly emphasizes the dissemination and utilization of research evidence?

Section 2: Evidence-Based Practice Is the Way in Which Clinical Reasoning Unfolds or Should Unfold The assumption underlying this conceptualization is that EBP is how clinical reasoning is manifested. It suggests that clinical reasoning takes the form of EBP, and as such, clinical reasoning is, and becomes a part of, clinicians' decision-making process. This conceptualization also assumes that all clinical decisions are, or ought to be, based on evidence. Thus ‘evidence’ of good clinical

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reasoning is through the ‘doing’ of EBP. In this case if one accepts that EBP leads to better patient care and improves transparency, accountability and value, as has been suggested in the literature (Emparanza et al., 2015), then EBP is the way we ‘should’ make decisions about clinical care. Consequently, if clinical reasoning is ‘best’ manifested as EBP, it shouldn't be ‘one of the ways to do it’ but rather a ‘first among equals’ way of reasoning. Consider three distinct instances of decision making. A physician must order and justify the use of a series of diagnostic tests for acute onset of abdominal pain; a healthcare team must decide if a patient arriving in the emergency department with debilitating headaches needs immediate hospitalization; an occupational therapist considers how to provide psychosocial support for a young mother newly diagnosed with multiple sclerosis who is caring for her 3-month-old infant. Existing scientific evidence has informed the development of care algorithms or contributed to practice guidelines concerning the most appropriate use of health resources. Does the ‘stepwise’ separation of scientific evidence from practice-based tools such as guidelines automatically divorce the enactment of these decisions from a frame of evidence-based tools? If good clinical reasoning is embodying the spirit (rather than solely the stepwise approach) of EBP, then reliance on guidelines for good practice or care algorithms could be considered a manifestation of EBP. We reflect on this stance in the following case study.

Case Study 13.1 Julie is a physiotherapist working in an inpatient rehabilitation centre specializing in musculoskeletal conditions. She is asked whether Mrs. Jones, her 79-year-old recently widowed patient with a new onset of falls, is a suitable candidate for an outpatient fallsprevention program offered in the community. Knowing that Mrs. Jones lives alone, that she has limited social support and is at risk for recurrent falls, Julie discusses the benefits of the program with Mrs. Jones and suggests that they look into transportation services. In this example, Julie is not formally searching for scientific research and not engaging in the ‘stepwise’ approach to EBP, nor is she appraising papers for their quality or relevance to Mrs. Jones'

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situation. She is, however, drawing from her practice knowledge of the effectiveness of fall-prevention programs to help her in suggesting and promoting the program to her patient. Most importantly, her ‘clinical decision’ is very much influenced by her in-depth knowledge of the lived experience and situation that her patient finds herself in. She ‘knows’ that a recently widowed older adult with limited social support may isolate herself by fear of being a burden on her family or putting herself at greater risk for falling by venturing out of her home more often. Yet Mrs. Jones refuses to participate. Her decision to forego the fall-prevention program is further justified given her limited access to transportation services to the community centre where the program is being offered. This sophisticated and presumably rapid decision-making process rests upon Julie's extensive knowledge base of the effectiveness of fall-prevention interventions for community dwelling seniors, the functional outcomes following falls and injuries and the typical developmental features of the aging process. Could Julie's decision about recommending the fallprevention program be made without evoking the scientific literature? In other words, could Julie conclude that this would be a beneficial program for her patient without having to go through the full formal EBP stepwise process? We suggest that it is indeed possible, particularly given the more modern broad definitions of EBP, and we posit that this situation occurs frequently. This scenario suggests that Julie is balancing various sources of knowledge and evidence. She is, therefore, engaging in EBP and is likely to be demonstrating good clinical reasoning. This reflects the notion that EBP is the way in which clinical reasoning does or should unfold. What are the possible downstream consequences of this view of EBP (Box 13.2)?

Box 13.2

Downstream Consequences of the View That EBP Is the Way in Which Clinical Reasoning 334

Unfolds or Should Unfold ▪ If EBP is the means by which clinical reasoning should unfold, what happens to the construct of clinical reasoning in the absence of a concrete final decision? Does clinical reasoning need the decision-making framework of EBP to ‘exist’ or to manifest itself? If one answers yes, how do we avoid a potential slippery slope whereby every decision, made under every possible circumstance, for all patients, in all contexts must by definition be made as a result of consulting or evoking the scientific evidence of some kind to be considered the result of ‘good’ clinical reasoning? This perspective suggests that without a decision being made, or without an evidence base to draw from, there is no evidence of clinical reasoning. Anything that is not EBP is suboptimal or inadequate clinical reasoning. If EBP is manifested in a less than ideal manner, is enacted ineffectively or leads to the wrong decision for a given patient in a given situation and context, then is this evidence of poor clinical reasoning? ▪ EBP, as defined in the literature and taught in many health professions education programs, is a deliberate, conscious process. If we accept the view that EBP is how clinical reasoning unfolds, then it follows that understanding, valuing and teaching reasoning modes that are not perfectly conscious, structured, reportable and teachable become challenging at best and likely become devalued as reasoning processes. ▪ If we accept a broad definition of EBP in which scientific evidence, experiential knowledge and patient preferences are valued, the assumed necessary reasoning processes include the collection of ‘evidence’, the interpretation of that evidence and the balancing of that evidence across the three components of Fig. 13.1. If this is the interpretation of EBP being adopted, we assume that the framework of EBP is how reasoning ‘should’ unfold, then applying an EBP frame to the study of clinical reasoning may actually provide a more concrete structure through which to study the relatively nebulous concept of clinical reasoning. ▪ Finally, one could speculate that a consequence of disregarding

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contributors other than EBP approaches to clinical reasoning could result in devaluing professional expertise, which in turn can lead to professional dissatisfaction and clinician resentment towards efforts aimed at promoting EBP. Indeed, there are many lessons learned from earlier studies exploring attitudes towards EBP. Earlier studies showed clinicians’ less than favourable perceptions of and attitudes towards EBP were in part a result of an overemphasis on scientific evidence to the detriment of professional experience and expertise and the role that clinical reasoning plays in decision making (Dubouloz et al., 1999).

Areas for Future Research If we accept that EBP is the way in which clinical reasoning unfolds or should unfold, we propose the following questions for discussion and future research. 1. If EBP and clinical reasoning are interdependent, efforts should be directed towards merging the areas of compatibility across these two areas. More specifically, if we adhere to the notion that clinical reasoning is best enacted through EBP, then are there particular conceptualizations of clinical reasoning (Young et al., in press) that are more amenable to the valuing of evidence and the consideration for EBP as a means to enact clinical reasoning? If such a conceptualization does not exist, could the health professions education community benefit from multidisciplinary efforts towards developing one? 2. If we agree that without EBP there is no clinical reasoning, how do we avoid the potential negative effect on the autonomy and professional experience of clinicians and/or their profession? If clinical reasoning is a careful balancing of the evidentiary sources in Fig. 13.1, would it be possible to consider the de-professionalization or atomization of clinical practice? How would this view affect the many other roles expected of a healthcare practitioner such as effective communication or advocacy or the dynamic adapting of a management plan in situation such as when a

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clinician is attending to a patient's distress or fear? Or when a clinician is interacting with individuals experiencing lifealtering health challenges? Moments and interactions that strengthen the therapeutic relationship could be said to allow for a deeper connection if for no other reason than to create a strong therapeutic bond. Are we losing a part of what it means to be a healthcare professional? These are building blocks for many successful clinician–patient interactions. And what if this view succeeds in alienating clinicians by undervaluing clinical decisions that are meant to deepen the therapeutic bond? 3. If EBP is how clinical reasoning unfolds, do we need to understand ‘the balancing’ of different sources of (potentially conflicting) evidence? If this is how clinicians ‘should’ reason, should we try to understand EBP as an overarching process or frame for clinical reasoning? 4. If EBP is the larger or overarching concept, does this mean that it loses some of its precision inherent in some of the earlier models of a deliberate stepwise structure? As an overarching concept it becomes more flexible, allowing for latitude and what it attempts to achieve. However, does it also deserve more attention regarding its potential complexity?

Reflection Point 4 How does this interpretation match your view of the relationship between EBP and clinical reasoning?

Section 3: Evidence-Based Practice and Clinical Reasoning Are Different Words/Frames for the ‘Same Thing’ Are EBP and clinical reasoning different sides of the same coin? In this last stance regarding the relationship between the two processes, we propose that both clinical reasoning and EBP are approaches to clinical decision making representing means to

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arriving at a clinical decision. EBP combines evidence, patients' input and clinician experience, suggesting that these are, as mentioned earlier, interacting with the purpose of making a final decision. Clinical reasoning, though a fragmented literature, has also been discussed as a means to an end, a process used to establish a diagnosis to decide on and implement the best possible course of action (Eva, 2005). Although clinical reasoning has been informed by a variety of theories, stances and perspectives, a common theme among these approaches has been the notion that clinical reasoning produces diagnoses, management plans or investigative plans – that it ends in a decision (Durning et al., 2013; Eva, 2005; Young et al., in press). Viewed in this way, clinical reasoning and EBP are both processes or approaches used to come to a decision, whether that decision is about a diagnostic test, a discharge date, admitting a patient to hospital or assessing an older adult's competence to care for himself or herself. Though the components or nature of these processes is not trivial or inconsequential given that they likely contribute to the end goal (i.e., clinical decisions), they may take a ‘backseat’ to the actual decision. Alternately, clinical reasoning and EBP could be two different families of approaches to the study of how clinical decisions are made – with different areas of focus, importance and value stances as to what are important contributors to the process of generating a clinical decision and shaping the research within each field. Clinical reasoning and EBP have emerged from different disciplinary areas; clinical reasoning emerged primarily from cognitive science and psychology and EBP from epidemiology, and as such, may have concretized different areas of focus or importance for the same set of processes. Although this interpretation remains speculative, and likely contentious, it is an area for future research. Consider the downstream consequences of this view (Box 13.3).

Box 13.3

Downstream Consequences of the View That EBP and Clinical Reasoning Are Different Words/Frames for the ‘Same Thing’ 338

▪ Accepting this view suggests that the component processes are less important than the quality of the eventual outcome – as long as a decision is made, how the individual ‘got there’ is not as important. We propose that this has potentially precarious implications for teaching and assessment, particularly given the increasing attention to assessing process of learning and outcomes (Bransford et al., 2000; National Research Council, 2001). ▪ If EBP and clinical reasoning are indeed two different sides of the same coin but remain largely in different research silos, we are not advancing the knowledge base nor well situated to move our field(s) forward. We may actually be failing to clarify concepts that may reflect only linguistic differences rather than conceptual ones.

Reflection Point 5 How does this interpretation match your view of the relationship between EBP and clinical reasoning?

Areas for Future Research If we agree that EBP and clinical reasoning are different words/frames for the ‘same thing’, we propose the following questions for reflection and discussion. 1. We propose that the research community should find areas of overlap, similarity and differences across these bodies of work to deepen our understanding of these key principles. 2. What main messages do we want to send to educators and scholars who teach, assess and study decision making in and out of the classroom? 3. If EBP and clinical reasoning are a set of processes, what cues would be available to us to see ‘high-quality reasoning or decision making’ whether labelled as clinical reasoning or EBP? 4. How can we best design teaching, assessment and continuing professional development activities to align

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with, and to promote EBP and clinical reasoning?

Chapter Summary This chapter presents three different stances regarding the relationship between clinical reasoning and EBP. We have deliberately not chosen to privilege one of these views. Rather, we have presented them critically, considering practice, education and research implications. We invite you to reflect on your own stance to the relationship, areas of overlap and areas of differentiation between these two concepts.

Reflection Point 6 Do the arguments presented in this chapter reflect your current stance on the relationship between EBP and clinical reasoning? Do they prompt you to consider a new stance? What implications arising from this discussion might lead you to make a change in your practice?

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14

Methods in the Study of Clinical Reasoning Jose F. Arocha, Vimla L. Patel

CHAPTER AIMS This chapter aims to: ■ provide a description of the most used methods for the investigation and assessment of clinical reasoning, ■ classify such methods in terms of their nature and unit of analysis and ■ show how the methods can be of utility for the study of clinical reasoning.

KEY WORDS Clinical reasoning (CR) Thinking Quantitative methods Qualitative methods

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Introduction Methods for the study of clinical reasoning are often selected based on the philosophical outlook considered by the researcher. Philosophically, quantitative methods are said to be characteristic of a positivist methodological approach to research, which posits the essentiality of quantifiable behaviour in the conduction of scientific research. In turn, qualitative methods are often based on a philosophy that proposes the constructive nature of human thought and action. Despite the difference in outlook, there has been a recent push to investigate thinking within a framework that forgoes to some extent the philosophical chasm between quantitative and qualitative research, while adopting a more pragmatic approach to research. From our view, this situation has positively affected the study of clinical reasoning. Indeed, its study in the fields of health has positively changed in recent years. Some of the major changes are the following: First, some theories, notably dual-process theory (Croskerry, 2009), have become widely used to guide research studies and to explain cognitive processes, such as problem solving and reasoning. Second, new and not so new methodologies have been introduced and applied to the investigation of such processes, which promise to better elucidate what goes on when a clinician interprets a patient problem. Third, the traditional and clearly delineated distinction between quantitative and qualitative research methods has become fuzzy (Haig, 2013), as new research increasingly makes use of both approaches in clinical reasoning investigations (e.g., Rice et al., 2014). Fourth, although in previous years the study of clinical reasoning was mostly focussed on medical tasks, there has been increasing research in other health fields, such as occupational therapy (Cramm et al., 2013), physiotherapy (Langridge et al., 2015) and nursing (Stec, 2016). Methods of investigation of clinical reasoning can be grouped into those that look at outcomes to hypothesize the underlying cognitive processes and those that explore the processes of reasoning themselves. We found it useful to classify methodologies as quantitative or qualitative to the extent to which they generate numerical or verbal/gestural data. Also, some can be aggregated into statistics, while others are less suitable for aggregation. Specific

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studies can, of course, vary and use quantitative methods to identify average differences between groups together with qualitative methods to characterize individual performance (Patel et al., 2001). This chapter is devoted to the study of clinical reasoning as an individual process, leaving out methods designed to capture clinical reasoning as it occurs in teams or work groups (e.g., Patel et al., 2013).

Quantitative Methods Quantitative methodologies for investigating clinical reasoning have been used in various clinical problems. One of them is the study of diagnosis in perceptual tasks, such as x-ray or dermatological image interpretation (Jaarsma et al., 2015; Norman et al., 1992), where study participants are shown a series of slides after which they are asked to interpret or recall the information of the visual material. A goal of this research is to show how variations in the participants’ performance (e.g., assessed through verbal recall) relate to variations on the experimental conditions (e.g., types of stimuli). These data are then quantified, using descriptive statistics and subjected to standard statistical analysis (e.g., null-hypothesis testing). These methods have also been employed to compare clinical performance by groups with different levels of expertise (Norman et al., 2007). The study of group differences serves to estimate population parameters. However, quantitative methods can also be used for investigating individuals (Runkel, 1990), although unfortunately little use has been made of such methods for this purpose. Next, we cover specific quantitative techniques recently applied to the study of clinical reasoning.

The Script Concordance Test The Script Concordance (SC) test has gained considerable attention in recent years (Charlin et al., 2007). The test, theoretically based on script theory (Schmidt and Rikers, 2007), poses that clinicians develop increasingly coherent knowledge structures, called scripts, as their experience increases from students to seasoned practitioners (Schmidt and Rikers, 2007). The test is also informed by dual-process theory. As clinicians’ expertise increases in a given

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health field, they also develop two distinct thinking processes: ‘analytical’, which is slow, effortful and more characteristic of novices and ‘nonanalytical’, which is fast, subconscious and more characteristic of experts. The SC test (Charlin et al., 2000; Lubarsky et al., 2013) is a psychometrically validated written instrument particularly designed to assess clinical reasoning. The test is normally developed with the help of a group of experts, who generate vignettes describing clinical cases and provide interpretations of the cases. The vignettes should allow for different interpretations to reflect the various expert judgements and should not assume a single correct answer but alternative interpretations based on the response variations found among the experts who developed the vignettes. The interpretation selected by most experts is taken to be the ‘best’ answer, although other responses are also considered to be reasonable. After a case is introduced, a series of questions with several hypotheses below are presented. The questions are of the form ‘If you were thinking of [e.g., diagnosis, investigation, treatment] and then you find a new [sign or symptom], your diagnosis becomes more or less likely [selected on a scale ranging from –2 to +2]?’. By presenting the case in partial form, adding new information at a time and asking whether the selected hypothesis becomes more or less likely, the test can capture parts of the reasoning process. The SC test has been applied successfully in several health settings (e.g., Carrière et al., 2009; Kazour et al., 2017). Its relative ease makes the SC test an appealing way of studying clinical thinking. Computerized or online forms of the test are likely to make it even easier (Sibert et al., 2002). However, researchers should be aware of some validity and reliability concerns with the standard application and interpretation of SC test results (Lineberry et al., 2013).

The Repertory Grid Technique The repertory grid technique was developed by George Kelly (1991) to elicit and examine the personal constructs (e.g., personal beliefs) people use when interpreting a problem or situation. The theory posits that people interpret the world around them much like a scientist, generating hypotheses to understand and predict events.

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Kelly viewed personal constructs as existing along a bipolar dimension, where one construct was conceived in relation to its opposite, for instance, viewing a problem along the dimension of ‘easy’ versus ‘difficult’. Thus one assumption is that people's personal constructs can be elicited by placing them at some distance between two poles of the dimension. A benefit of the repertory grid is that it can be quantified and statistically analyzed at the individual level. The method has been applied to the study of clinical reasoning (Kuipers and Grice, 2009a, 2009b). Kuipers and Grice (2009a) illustrate the use of the technique by analyzing an interview with an expert occupational therapist. The expert's constructs were elicited from a vignette describing a patient suffering from a neurological problem and a question, called ‘element’, (e.g., ‘what is the first thing you attend to when you see the client?’), which prompted the expert to generate a series of personalized questions regarding a therapy session. These ‘elements’ were then used to assist the expert in eliciting the polar constructs along which each element was situated within a numbered grid (Box 14.1). For instance, the expert in the study judged the element mentioned earlier to exist between ‘assess functional issues’ and its polar opposite ‘reason and determine action’ by numbering the element along a scale, e.g., with 5, if closest to the emerging construct and 1, if closest to the opposite construct (Kuipers and Grice, 2009a, pp. 280–281).

Box 14.1

Script Concordance Although the Script Concordance test is an outcome measure, the partial presentation of data allows a reasonable representation of the reasoning process.The repertory grid is based on the idea that people generate personal constructs as scientists generate hypotheses to interpret the world. The method provided both qualitative data (from the interview) and quantitative data (from completing the grid). By applying a statistical method for finding clusters along dimensions in the data,

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called principal component analysis (PCA), it was possible to identify two components, labelled ‘therapist role’ and ‘practice scope’, which accounted for 83% of the variance in the expert's responses. Another study (Kuipers and Grice, 2009b) expanded the use of the repertory grid interview to explore differences between novice and expert occupational therapists before and after introducing a protocol designed to guide the process of clinical reasoning in cases of ‘upper limb hypertonia’. The research showed differences between the groups: the novices’ reasoning significantly changed their approach to be consistent with the protocol, while experts did not. Although the repertory grid technique has not been extensively used, it is a promising theoretically based method for the study of clinical reasoning. A basic introduction to the use of repertory grid can be found in Pollock (1986).

Neuro-Imaging Methods Recently researchers have looked at clinical reasoning processes using neuro-imaging methods (Chang et al., 2016; Durning et al., 2012, 2013b, 2016). The major aim of this kind of research is to uncover the brain structures that underlie the processes of reasoning and thinking. Basically, the method consists of carrying out one or more reasoning tasks while the study participant is in the functional magnetic resonance imaging (fMRI) scanner. The method has been applied to identify the neural structures involved in analytic and nonanalytic reasoning (Durning et al., 2015); memory structure and flexibility in thinking and the differences between experts and novices (Durning et al., 2016); the differences involved in answering questions versus thinking ‘aloud’ (Durning et al., 2013a); and clinical problem solving and recall by medical students (Chang et al., 2016).

Reflection Point 1 Some scientists and philosophers maintain that the key to understanding human reasoning is by uncovering the neural processes underlying thinking, and others maintain that many different approaches are needed to understand reasoning.

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Multiple-choice questions (e.g., items from the US medical licensing examination) are often used during the scanning process, although concurrent and retrospective protocols also have been employed (Durning et al., 2016). In a typical study, Durning et al. (2015) made use of dual-process theory as an explanatory framework and fMRI to investigate nonanalytic reasoning and thinking efficiency of internal medicine interns (novices) and boardcertified internists (experts). The method used involved presenting a series of timed multiple-choice questions (e.g., 60 seconds for reading and 7 seconds for answering) to the participants, which they had to answer by pressing a button while they were in the scanner. After providing the responses, the participants were allowed some time to reflect on their answers, which was done to assess analytic reasoning. The results showed that although sharing a great deal of neural activation (e.g., in brain areas responsible for pattern recognition), novice and expert physicians also demonstrated some differences in the brain areas involved and in reasoning efficiency. Although the results of fMRI may be sometimes difficult to interpret, the method shows encouraging applicability to the study of clinical reasoning in controlled situations (Box 14.2).

Box 14.2

CR Measures Clinical reasoning can be investigated with outcome and process measures. Using more than one kind of measure ensures a more complete description of clinical reasoning. Diverse measures involving biological, behavioural and cognitive have been developed.

Eye Tracking Eye-tracking technology has become more available, less intrusive, smaller and simpler to use. A benefit of eye-tracking technology is that it precisely measures gaze behaviour (e.g., number, location and duration of eye fixations) providing evidence of the

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information that the clinician can focus attention on. Today's eyetracking technology consists of nonintrusive small cameras that capture infrared light reflected on the cornea. Several eye-tracking studies have been recently conducted to investigate clinical reasoning (Blondon et al., 2015), where the method has been combined with concurrent or retrospective verbal protocols. The vast majority of the studies to date have been conducted in visual domains, such as radiology (Krupinski, 2010), to identify the location of lesions or in the utilization of information technology (Tourassi et al., 2013). A review of the literature by Blondon et al. (2015) identified 10 studies that in various degrees can shed light on the process of clinical thinking. In one study, Tourassi et al. (2013) investigated the diagnostic accuracy in the processing of mammographies within a novice-expert paradigm. They showed that decision making in diagnostic accuracy could be predicted by the patterns of gaze behaviour, which suggests that eye-tracking may be a valid indicator of clinical reasoning.

Case Study 14.1

Investigation of Reasoning Strategies A researcher is interested in assessing physiotherapy students’ clinical reasoning skills. She knows that there are several methods of doing this because she is familiar with outcome-based performance measures, but she would like to understand the different strategies that students use to arrive at the solution of a patient problem. If the physiotherapist aims at capturing the actual process of reasoning, what quantitative method is the most useful to meeting his or her aims?

Qualitative Methods Verbal Protocols The methods described in this section vary widely in terms of their origins and applications and cover concurrent (Fonteyn et al., 1993; Lundgrén-Laine and Salanterä, 2010) and retrospective (Elstein, 2009; Elstein et al., 1978) protocols. The more commonly used

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methods are the think-aloud and the explanation protocols. The first originates in the study of problem solving and computer simulation of thought (Elstein et al., 1978; Simon, 1993); the second originates in the analysis of text comprehension (Kintsch, 1998). In both cases, the researcher uses verbalizations as data, without involving introspection. That is, research participants are asked to verbalize their thoughts without ‘theorizing’ about their thinking. Examples of verbal report analyses can be found in Ericsson and Simon (1992) and Arocha et al. (2005).

Think-Aloud Protocol and Analysis Think-aloud is still an extensively used technique for the study of clinical reasoning (Lee et al., 2016; Lundgrén-Laine and Salanterä, 2010). This is not surprising given the difficulties of investigating cognitive processes without making use of verbal data. As in many other methods, think-aloud protocols are based on a theory, in this case, the information processing model of Newell and Simon (1972). The method, to be applied successfully, needs a period of training before it can be used to collect data and requires study participants to follow some stringent criteria. The criteria pertain to the type of task that should be used, the kinds of instruction given to study participants and their familiarity with the task. Although criticisms have been raised against the method, e.g., the potential effect of the verbalization itself on the thought processes, it has been found to produce a reasonable description of the underlying thinking process (e.g., Durning et al., 2013b). In typical think-aloud research, clinicians are presented with a patient problem, frequently in written vignettes. A vignette may contain anything from a single sentence to a whole patient record including the clinical interview, the physical examination results and the laboratory results. The clinician is asked to read the information and verbalize whatever thoughts come to mind. If he or she pauses for a few seconds, the experimenter intervenes with questions such as ‘What are you thinking about?’ or, more appropriately, with demands such as ‘Please, continue’, which encourages the clinician to carry on talking without introspecting. A detailed and lengthy description is provided by Ericsson and Simon (1992), although shorter introductions have been published

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(e.g., Lundgrén-Laine and Salanterä, 2010). Once the protocol has been collected, it is subjected to an analysis aimed at uncovering the cognitive processes and the information that were used. The analysis of the protocol is then compared with a reference or domain model of the task to be solved. This model is frequently taken either from an expert collaborator in the study or from printed information about the topic, such as textbooks or scholarly expositions. For instance, in an earlier paper, Kuipers and Kassirer (1984) used a model of the Starling equilibrium mechanism, which was compared with the clinician's protocol. Patel et al. (Arocha et al., 2005; Patel et al., 1994) also used a reference model of the clinical problem generated by exceptional practitioners, which serves as a standard for comparison with the obtained protocol. More recently, researchers in fields other than medicine have proposed (Lundgrén-Laine and Salanterä, 2010) and used the think-aloud method (Lee et al., 2016). In a recent study (Lee et al., 2016), a group of nurses were given two scenarios describing patients with complex chronic diseases and were prompted to think aloud while interpreting the problem. The protocols were used to develop a detailed model of the nurses’ reasoning process. Other researchers have used the think-aloud method in combination with other techniques. For instance, Power et al. (2016) used the method in tandem with the SC test. Also, Durning et al. (2013a) combined its use with fMRI imaging, and Balsev et al. (2012) had clinicians at different levels of expertise think aloud while solving diagnostic problems in paediatric neurology using eye-tracking technology.

Explanation Protocols Explanation protocols are a form of retrospective protocol in which people are asked to explain a case to the researcher while the person is being audio-recorded. The explanation protocol is based on a number of assumptions (Arocha et al., 2005). First, information, such as a clinical case description, is processed serially. The information generated from a clinical problem passes through working memory first and then is linked later to information in long-term memory, which provides context for interpretation. Second, the temporal sequence in an explanation protocol follows

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that of the underlying reasoning, in the sense that ideas that are verbalized first are processed first. Third, although the clinical problem may be the same, the reasoning strategies and the final response (e.g., final diagnosis) vary because people process clinical information at several levels of generality, from the very specific symptom level to the general diagnostic level. Research shows that the expertise of the clinician is the critical factor in determining the level of generality at which the clinical case is processed. Finally, both reasoning strategies and inferences used during clinical reasoning are a function of the clinician's domain-specific prior knowledge. In practice, the explanation protocol method involves asking research participants to explain the pathophysiology of a case. The transcription of the recorded session is analyzed using propositional analysis, which represents the propositional structure of the explanation. Analysis consists of several steps: 1) segment the recorded protocol into clauses; 2) identify the propositions, or idea unit, in each clause; and 3) connect the propositions to reveal the overall semantics of the protocol. A semantic network can be developed from the list of propositions by representing concepts as nodes and relations as links between nodes. Fig. 14.1 shows a network representation of a propositional analysis generated from a clinician's verbal protocol. The oval nodes indicate patientpresented data, the green box indicates suggested diagnosis and the white box indicates generated hypothetical symptom. The links indicate the direction of reasoning. The links from data to diagnosis refers to data-driven reasoning, and the link (in green) from diagnosis to hypothesis indicates hypothesis-driven reasoning. The text over the links designates semantic markers, e.g., ATT: attribute; CAU: cause; and COND: conditional. The resulting network is a connected conceptual that represents the information used and the process of reasoning the clinician goes through. The method has been used to investigate patterns of explanations in novices and experts (Patel et al., 1994).

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FIG. 14.1 Network representation of propositional

analysis generated from a clinician's verbal protocol.

Video Data Collection and Analysis Videotaping and video analysis can be very useful methodological tools for the study of behaviour and cognition. There are various uses of video-based data collection. A video camera can be used to capture the stimulus material, such as patient simulation, and a video monitor can be used to present material to the study participants (Durning et al., 2012). Video can also be used as a data collection tool, where the video camera is positioned externally to the study participant, e.g., for analyzing gestures, or can be used mounted on the participant's head (Pierce, 2005) to analyze the problem from the participant's point of view. It is especially the second use of video data collection that is more useful to the study of clinical reasoning (Unsworth, 2001b), especially when combined with concurrent or retrospective protocols (Box 14.3).

Box 14.3

CR Assessment ■ Qualitative methods comprise concurrent measures, such as the think-aloud protocol, and retrospective protocols, such as the explanation protocol. ■ Video data allow researchers to assess behavioural aspects of reasoning, such as gesture and actions, which can be used to provide extra information that could illuminate think-aloud protocols.

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A benefit of video data is that they can capture the context of reasoning. In fact, one may argue that videotaping and analysis allow for a more complete characterization of cognitive processing, by providing extra nonverbal information, such as gestures, movements and gazes, which complements the information obtained from verbal protocols. Video data are helpful in analyzing tasks designed to externalize someone's thought processes, for instance in physical therapy. In such tasks, both verbalizations and physical actions (e.g., pointing, gazing) can be analyzed in a more complete fashion. Video recording has been used in several health disciplines, such as kinesiology, to conduct computer-based analysis of movements, or speech therapy, to analyze language production problems (Pierce, 2005), among others. Several studies have been conducted in the health sciences using video recording and analysis (Bailliard, 2015). Roots et al. (2016) investigated osteopaths’ clinical reasoning while assessing patients with low back pain. The session was recorded of the interaction between the health practitioner and the patient. After the session finished, the therapist was asked to watch the recording while commenting on the session. This part was audio-recorded for later analysis. Research from the point of view of the study participant has been conducted by Unsworth (2001b). In a study of expert and novice occupational therapists (Unsworth, 2001a), a small camera was strapped around the therapist's head and used to record a typical therapy session with a client. The therapists did not need any time for practice because the head-mounted camera did not disturb their normal work. After the session, the therapists were asked to think aloud while the recording of the session was being shown on a monitor to facilitate recall.

Case Study 14.2

Choosing Method(s) A nurse administers a written test to research participants in a study. The nurse could not obtain think-aloud data because of some reasons related to the investigation itself, but the nurse would like to understand the knowledge participants’ use during reasoning. Given those aims, what qualitative method among the

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ones presented is the most suitable to answer the nurse's question? Video data analysis methods vary (Bailliard, 2015), ranging from qualitative to quantitative, the selection of which depends on the theoretical framework used, the objectives of the research and the nature of the data (Derry et al., 2010). Thematic or behavioural analyses exist, both top-down (i.e., categories are generated in advance) or bottom-up (i.e., coding is generated inductively from the data). These analyses can be carried out with the help of video software, which is commercially available.

Conclusion The panorama of current research methods for the study of clinical reasoning has changed a great deal. First, methodological pluralism is now a common occurrence in research studies. Although one may argue that a methodological fragmentation still exists, it is inspiring to see different methods used in single clinical reasoning studies. The distinction between quantitative and qualitative research methods is now less important as researchers make use of think-aloud in tandem with eye fixations, fMRI, video recording, repertory grids and the SC test. This way, data can be collected and analyzed that integrate numerical information with qualitative descriptions, which facilitates the comprehension of what goes on during clinical reasoning at several levels, from the purely behavioural, to the cognitive, to the neural. Although early research into clinical reasoning was somewhat characterized by methodological isolation, new methods and techniques have become increasingly used to capture different aspects of the same phenomenon. Approaching the study of clinical reasoning from different perspectives and integrating methods in single studies may facilitate a more complete understanding of the underlying processes and the settings where reasoning is deployed. Second, although not covered in this chapter, other major changes have occurred in the way clinical sciences are practiced that may require methodological approaches that permit a fresh look at the processes of reasoning. Clinical reasoning can be considered, in the case of medicine for instance, as thinking through the various aspects of patient care to make a decision about the diagnosis or the

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therapeutic management of patient problems. This includes historytaking, physical examination, ordering laboratory and ancillary tests and making evidence-based patient management plans. The increasing amount of research in allied health areas, such as nursing, occupational therapy, social work and physical therapy, has extended the scope of clinical reasoning to a variety of tasks not typically thought within its purview. Furthermore, given the considerable variety of these tasks, clinical reasoning can no longer be considered as a characteristic of the single individual only, as it is being increasingly done by teams and collaborative groups often through technological means, such as the electronic health record and decision support systems. The nature itself of clinical reasoning may need to be reconsidered and tackled with new eyes with the help of novel methods that can capture, holistically, the interactive processes generated by clinicians, patients and technology.

Chapter Summary In this chapter we have presented:

■ a description of selected methods for the investigation of clinical reasoning in the health professions, ■ examples of their use in research on clinical decision making and thinking in medical and other healthcare settings and ■ comments about future methods and their potential integration to provide a more complete picture of the process of clinical reasoning. Reflection Point 2 Consider what research questions you might pose if you were planning to research clinical reasoning. What methods would be useful for researching these questions?

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SECTION 3

Collaborative and Transdisciplinary Reasoning OUTLINE 15 Collaborative Decision Making in Liquid Times 16 Ethical Reasoning 17 Shared Decision Making in Practice 18 Using Decision Aids to Involve Clients in Clinical Decision Making 19 Clinical Decision Making, Social Justice and Client empowerment 20 Clinical Decision Making Across Orthodox and Complementary Medicine Fields

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15

Collaborative Decision Making in Liquid Times Franziska Trede, Joy Higgs

CHAPTER AIMS The aims of this chapter are to: ▪ consider the importance of our liquid times for decision making, ▪ support critical social science as a basis for collaborative decision making and ▪ encourage practitioners to develop, critically, their own collaborative decision-making practices.

KEY WORDS Collaborative decision making Clinical reasoning Critical social science

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Introduction Healthcare practice is rapidly changing with advances in technology in a globalized world. The way we practice, communicate and relate to each other is relentlessly changing and with it the way we make decisions. Decision making in healthcare practice is an important clinical reasoning process and issue. It has impact on efficiency and consequences for effectiveness. In a simple (science-driven) world, healthcare practitioners would make expert decisions based on scientific empirico-analytical evidence that promises the best health outcomes. In this world, patients would concur with the expert decision and carry out the behaviours required. This vision portrays decision making from a biomedical model perspective, where the roles of patients and healthcare practitioners are clearly defined. Decision making affects not only patients, their families and carers but also healthcare teams and services. Furthermore, decision making occurs within sociopolitical contexts. Decisions about postsurgery treatment in a first-world country with free healthcare insurance looks different from that of developing countries. Further, the decision-making process needs to include economic, educational, cultural, ethical and material considerations. Whose interests are being considered? Whose interests prevail? What role is played by hospital budgets, bed occupancy, views about good health and the pursuit of a quality life? What else should be included that enables responsible, morally justifiable, productive and effective decisions? In this chapter, we focus on collaborative decision making and explore the new conditions of decisionmaking processes in liquid times (or times of rapid change, where the only real constant is change itself), discuss conceptual perspectives and principles of collaborative decision making and report on a critical practice perspective on collaborative decision making. See later in the chapter for further discussion on liquid times.

New Conditions of Decision-Making Processes in Liquid Times 368

Decision making is part of everyday healthcare practice. Many decisions can be made in a largely routine manner and require little conscious effort such as how to greet a patient, position oneself in relation to a patient, read progress notes and so on. In relation to sharing decision-making processes with patients and others, this was not routinely part of traditional health care. Today in thinking about shared decision making, a number of considerations arise. What questions should be asked? How can we encourage patients to reveal their expectations, hopes and fears? What label should be used to describe a diagnosis? What treatment options should be discussed? All these questions relate to providing a context and boundaries for shared discussions. The way decisions are made affects patients’ motivation, persistence with treatment, sense of ownership, control and perceptions of healthcare outcomes. The more patients are involved and participate in the decision-making process, the more likely they are to be well informed, involved, satisfied and feeling valued (Trede and Higgs, 2003). It is equally likely that healthcare practitioners who enable collaboration come to understand their patients better, practice person-centred care more deeply and rolemodel respect and curiosity more authentically. Many factors support the case for collaboration in decision making, and these factors have been well documented (Elwyn et al., 2012; Lin and Fagerlin, 2014; Matthias et al., 2013). These include ethical issues related to quality of life, end-of-life decisions, legal issues regarding informed consent, patient's rights for selfdetermination, patient safety, culturally appropriate care and valuing of diversity. Many patient complaints about health care relate to dissatisfaction with communication aspects of health care including poor communication skills of healthcare practitioners and breakdowns in communication. Potentially, collaborative decisionmaking processes could be a means of overcoming some of the causes of poor communication. Collaboration and communication are considered as important as delivering quality health care. These expectations are influenced by such factors as changing attitudes to health and patients’ rights, increasing cultural diversity of concepts of what constitutes good health, advocacy of community support and patient groups, increasing litigiousness, improved patient education, increased access to healthcare information via the

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Internet and organizing of self-help groups online. The world of healthcare practices and systems has been evolving over the centuries and continues to do so. However, over the past decade and with the arrival of mobile technology, health care, including conditions for practicing and collaborating in health care, has changed radically. As Floridi (2015, p. 131) argued, our thinking, doing and relating ‘is fluidly changing in front of our eyes and under our feet, exponentially and relentlessly’. The new ways of practicing that are fast, public and open, made possible by digital and mobile technologies, have made the old way of doing things redundant because they no longer suit these new conditions. These changes bring with them the increasing contestation of the notion and superiority of ‘the knowledge expert’. The role of privileged and restricted knowledge owned by individuals and professional groups that underpinned decision making (performed by experts for their clients) needs to be rethought. We live in transitional times, where it remains unclear what knowledge, practices and structures will be redundant, what will persist and what new will emerge. In short, we live in uncertain, ambiguous times. Zygmunt Bauman (2012) coined the concept of ‘liquid times’ to give expression to the current times we live in. He makes two key points about his term ‘liquid times’. Liquid times are marked by rapid change, where the only constant is change itself. The changes we are experiencing are much more fundamental and rapid than ever before. The term ‘liquid times’ describes how the concept of time has quickened. Knowledge, practice and structures liquefy before they have had time to solidify. Bauman explains that old, solidified ways of doing are no longer working, but new ways of doing have not yet been established, and there is no clarity in where new directions lead. The focus is now on immediacy, on short-term outcomes and instant impact. Holding on to old ideas and longterm commitments can be seen as being outdated. Thus standing still or slowing down is seen as a risk in liquid times. In this context, long-term thinking and long-term goals have collapsed and have been replaced by strategies that focus on being agile and keeping up with the latest developments. The second assertion Bauman makes is his observation of a separation between power and politics. The regard for knowledge is decreasing, giving way to feeling. We live in postfactual times,

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where it is increasingly difficult to distinguish between real and fake news. The idea of hard facts is changing to notions of fluid facts where new insights are generated more rapidly. The lifespan of knowledge is shortening more than ever before. We need to rethink how we interact with knowledge and news. This weakens certainty, control and authority. It also can undermine agency and confidence. The rapid developments in digital and mobile technologies provide a clear illustration of Bauman's argument. With digital and mobile technologies, boundaries are blurring between professions and laity, between personal and professional, and between producer and consumer of services. In this context, predictability and certainty are increasingly unattainable. We have given up on modernity – the quest for certainty and control – and now live in liquid modernity, the acknowledgement of the need to align with complexity, diversity and ambiguity. Bauman (2012) describes liquid modernity as a world where ‘[e]verything could happen yet nothing can be done with confidence and certainty’. Liquid times remind us to stay humble. It is important to be mindful that not everything is liquid. Liquidity on its own would be meaningless. It becomes meaningful only in an interdependent relationship with solidity, where one without the other could not exist (Bauman, 2012). Not everything is fluid, and not everything is solid. Without understanding and appreciating the role of solidity, it would be impossible to understand and appreciate liquidity. Both provide opportunities and barriers, and weighing up both enables deliberate professional decision making. Liquid times can be threatening, but there are positive effects to living and working in liquid times, especially when it comes to collaborating in decision making. It makes collaboration an imperative. In an increasingly complex and diverse healthcare landscape, collaborative decision making seems a desirable and productive way to proceed. It brings people together and engages with diversity. Healthcare models with strong and closed borders and rigid roles are no longer conducive to timely, safe and effective healthcare delivery. Instead, complex and global health problems and rich human diversity are in a state of constant increase that cannot rest secure in the context of a single discipline, one healthcare model or one school of thought alone, as such rigidity

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cannot provide the answers and solutions. Instead, interdisciplinary, collaborative decision-making practices are needed in liquid times.

Reflection Point 1 How have you experienced liquid times? Have you encountered systems that are too rigid and unchangeable to cope with liquidity in healthcare contexts?

Conceptual Perspectives and Principles of Collaborative Decision Making Readiness for Collaborative Decision Making Is Not a Given It cannot be taken for granted that patients (and clients) will be ready for and agree to participating in clinical decision-making processes or share in the responsibilities for clinical decisionmaking outcomes. Therefore practitioners need to check on patients’ readiness and willingness to collaborate in decision making about their health care. Patients enter healthcare situations with a wide range of preparedness for the events that will unfold during their journey of ill health or disability and limited preparedness (usually) for the processes and opportunities for decision making they will encounter. They may or may not have had time to investigate the nature of their condition or its medical management, to prepare mentally, physically or emotionally for the health situation they are facing and to develop a position on what they want or hope their health outcome to be. In addition, they commonly do not have the relevant medical knowledge or expertise to understand adequately the nature of the condition, its treatment options and potential health outcomes.

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Agreement to Participate in Collaborative Decision Making Needs to Be Checked via Informed Consent Agreements (to participate and agreements about outcomes) need to be checked because patients may only indicate implicit agreement through apparent compliance with treatment or healthcare programs. Practitioners need to consider whether agreements are real rather than apparent and genuinely collaborative rather than a matter of compliance in the face of unbalanced power. To do this, practitioners need to ensure an authentic collaborative decision-making process is enabled, taking complex factors into consideration.

Many Factors Influence Patients’ Agreements About Decisions – Yes May Not Mean (Informed) Yes When it comes to the point of agreeing with a healthcare professional or healthcare team in decision making, the patient's agreement could be influenced by many ‘entry’ factors. Any agreement or otherwise could also be influenced by factors within the communication or interaction, such as the relationship built with the practitioner(s), language or cultural familiarity or barriers, aspects of behaviour such as intentions, motivations and practitioners’ practice models (e.g., biomedical, biopsychosocial and emancipatory models). In addition, decision-making processes are influenced by professional authority, professional roles and expectations held by professional groups and the community.

Agreement May Be Apparent and Unchallenged Rather Than Genuine and Empowered When clinicians and patients share the same values, intentions and interests, agreement is more likely. However, agreement or compliance that is unarticulated or unquestioned may not be true agreement at all. It is tempting to assume that patients adopt the

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role that practitioners assign to them, without checking with patients either at the point of decision making or during subsequent treatment programs whether these roles are acceptable in terms of both ability and choice. Are patients reporting honestly on their perceptions of progress or their pain levels and so on? Considering a critical perspective to decision making reminds us that commonality of values and interests between patients and practitioners should not be taken for granted.

Conceptual Models of Shared Decision Making The traditional way of decision making that was entrusted to expert practitioners no longer fits the new conditions where patients are not only encouraged but frequently expected to participate in their treatment decisions (Lin and Fagerlin, 2014). Today is the time to reframe the notion of decision-making experts to include practitioners and patients. Most of the literature on decision making has a tendency to use the term ‘shared decision making’ but then discusses a great diversity of decision-making processes that range from paternalistic to informed decision making (Lin and Fagerlin, 2014). Makoul and Clayman (2006), in a systematic review of the literature on shared decision making, found great fluidity in what was understood by the term, ranging from clinician-led decision making across a spectrum to patient-led decision making. The authors listed essential elements of shared decision making: defining the problem, presenting the options, identifying patient values and preferences and doctor knowledge, and clarifying understanding. This checklist reflects the transactional procedures in decision making. Although this is a useful start, it falls short of considering contexts and deep-rooted motivations for collaborating. Matthias et al. (2013) argued that shared decision making cannot be discussed out of context and requires consideration of the entire patient encounter and particularly the nature of the patient– practitioner relationship. Mulley et al. (2012) asserted that excluding patients from decision making can be the reason for misdiagnoses. And Charles et al. (1997) summed it up succinctly in the subtitle of their seminal paper ‘It takes at least two to tango’.

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What the literature is pointing to is the importance of integrating various interests and motivations that influence the reasoning behind decision making. To this end, it is useful to consider a series of questions that helps clarify assumptions about decision making and how knowledge is generated (Edwards et al., 2004).

Reflection Point 2 Clarifying assumptions about decision making • When is it appropriate to be practitioner-centred, and when is it appropriate to be patient-centred? • Who has permission to define the problem? • Who is authorized to identify and legitimize what all the options are? • How are patients invited and encouraged to share their values? • Whose understanding needs clarification? • What counts as knowledge and evidence?

The Primacy of Interests: a Critical Model for Collaborative Decision Making In Chapter 4, we discussed the work of Habermas (1972), who developed a theory of knowledge and human interest (1972). Interests are the motivations, intentions and goals that guide behaviours. Of Habermas’ three interest categories (technical, practical and emancipatory) we see emancipatory interests as most relevant to the liberatory goals mentioned earlier that are linked to genuine patient-collaborative clinical decision making. Fig. 15.1 illustrates the extreme ends of the various interests that shape practice models.

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FIG. 15.1 Practice approaches.

Many scholars have delineated the dualism between practitionercentred and patient-centred care (e.g., Arnetz et al., 2004; Lin and Fagerlin, 2014), leaving the reader and practitioner appreciating differences between these terms but not helping them to communicate and transcend this dualism. A critical perspective in this context starts with critical self-awareness of what motivates professional bias, professional authority and professional roles, and it illuminates the various interests and interpretations underpinning practice approaches, especially those interests that pursue and drive power rather than reason. For example, adopting a critical perspective means seeking first to understand the historical and social factors and influences that have led practice to be accepted and valued the way it is (in a given context) and then to challenge and change this practice with the goal of emancipating those who are restricted or disempowered by it. Within this framework, practitioner-centred practice is typically practice that favours technical rationalism and privileges those in power (commonly the practitioners), whereas in truly (critical) patientcentred practice the practitioner seeks to share knowledge and power with the patient and to respect the input the patient can make to clinical decision making and healthcare management. Box 15.1 presents arguments in favour of adopting a critical perspective on collaborative decision making.

Box 15.1

Adopting a Critical Perspective in 376

Collaborative Decision Making When adopting a critical perspective in collaborative decision making, remember the following: ▪ Not all parties involved in the decision-making process necessarily share the same values, intentions and interests about health beliefs and health behaviours. Decisions need to be negotiated free of coercion and power imbalances. ▪ Decision-making roles of practitioners and patients are dynamic and change as the health condition of patients progresses from acute, life-threatening to subacute and chronic conditions. Therefore, it is important to make conscious choices about which approach to decision making is appropriate. ▪ Patients are increasingly better informed, and they (or at least many of them) want to know their options and be involved in decision making and self-management. ▪ Given appropriate opportunity and inclusive environments, most patients can be empowered to collaborate in decision making and have a say in their health management. Collaboration is based on the conviction that inclusiveness and critical self-reflection produce better outcomes for patients than empirico-analytical precision. Collaborative decision making is based on inclusive evidence that entails embracing uncertainty and recognizing diversity of patients, clinicians and therapeutic environments (Jones et al., 2006). A critical approach helps practitioners to become conscious of their interests and choices in decision making because hidden agendas and bias are made explicit. We see collaborative decision making as a strategy enabling practitioners to liberate themselves from unnecessary constraints to work authentically with patients to empower patients to reclaim responsibility for their health, autonomy, dignity and selfdetermination. The intention of collaboration in critical practice is to engage in dialogue and to democratize roles. Collaboration starts with critique, scepticism and curiosity to deepen understanding and to identify the scope of common ground for change. In our

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work, we have found that critique of decision making focussed on four closely interrelated dimensions:

▪ capacity for critical self-reflection, ▪ rethinking professional roles, ▪ rethinking professional power relations and ▪ rethinking rationality and professional practice knowledge. Reflection Point 3 In what ways do you see collaborative decision making as liberating for practitioners and patients?

Operationalizing Collaborative Decision Making In Chapter 4, we reported on five prototypes (the uninformed, the unconvinced, the contemplators, the transformers and the champions) that represented the way the participants in a research project (Trede, 2008) engaged (or did not engage) with a critical perspective in their practice. Here we take each of these prototypes in turn and consider their implications for collaborative decision making.

The Uninformed In Franziska's research (Trede, 2008), the uninformed were participants who were not aware of conceptual ideas of a critical practice perspective, their own interests and how those interests influenced their decisions; they often said they did not know what their patients really wanted and what their goals were. The uninformed group's practice interests were blurred. Practitioners did not think in terms of models or interests but reacted to presenting challenges. There seemed to be a lack of reflexivity. The uninformed had unknowingly adopted the mainstream approach to

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decision making. However, there was a tendency towards technical rather than emancipatory interests. One participant learned about collaborative reasoning by reflecting upon a critical incident that made her question the way she tended to make clinical decisions (Box 15.2).

Box 15.2

Being Uninformed The penny dropped for me only after 10 years of clinical experience. I had [a patient with] an above-knee amputation, and he had a prosthesis. He walked perfectly in the gym. I had him walk without a limp. I was really pleased with all this. Then I met him downtown in the shopping centre: he had his knee locked, he was walking on the inner quarter of his foot, foot stuck out at right angle, and he was perfectly happy. I stood and looked at him and thought ‘I can make you walk perfectly without a limp, but you don't want to do that’. And you know when he came to treatment he would do it, but obviously he wasn't feeling safe, and he didn't want to do it that way and that is that. I think I wanted him to do what I wanted. I was trying to be a perfectionist. And it has also to do with all the other physiotherapists. They are checking on you that you are doing it all properly. (Jill) Seeing her patient mobilizing in a nonideal way but with confidence and seeing him integrated into social community life made Jill start to question her goal-setting practices and her professional interests. Why should she make patients walk without a limp if all they wanted was to walk safely? Jill became aware of clashes between professional and patient goals. She was aware of peer expectations, and she felt pressured to comply with the professional physiotherapy culture. Collaborative decision making is influenced not only by the stakeholders of decisions but also by the practice culture and the workplace environment.

The Unconvinced Dorothy, who fitted the unconvinced prototype, equated

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collaboration with compliance. She felt that patients had to understand physiotherapy reasoning, but she did not think that physiotherapists had to understand the way patients reasoned. She did not challenge the biomedical interests that influenced the way she reached decisions (Box 15.3).

Box 15.3

Being Unconvinced Giving the patients options is definitely making them feel more in control, and you get a better response out of them. They don't just feel like sitting there having things done to them. They are having a bit more of a say what is happening to them. So it is good for both. (Dorothy) Dorothy experienced working in collaboration with patients as positive. However, her understanding of collaboration was narrowly defined because she limited the patients with whom she chose to collaborate. She noticed that patients who shared her values and expectations made her more relaxed, and she was able to give them choice. These patients did not challenge her practice. What Dorothy described as collaboration was patient compliance. With difficult patients, she felt she chose to be more forceful. She categorized patients who did not agree with her as difficult people with stubborn personalities. It appeared that either patients worked with her, or she had to use professional power to get patients to comply. She did not acknowledge her motivations and interests, and she did not practice self-critique.

The Contemplators The contemplators struggled with the concept of collaboration and patient emancipation. They interpreted collaboration as allowing patients to dominate them, and they rejected this approach to decision making. However, they could see some benefits in trying to work with patients by ‘making practice suitable to the patient's background, as much as their biomedical illnesses allowed’. Petra understood collaborative decision making as persuading

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patients to adopt the physiotherapist's perspective. It was not based on egalitarian, equal terms; the biomedical perspective prevailed unchallenged. Petra's practice values remained firmly grounded in the acute medical model despite appreciation of patients’ individual fears and needs. Petra believed that once patients were familiar with their acute conditions, they could be empowered to take more control and determine their own treatment routine in consultation (Box 15.4).

Box 15.4

Being a Contemplator Doing-to patients saves lives and prevents complications. Doing-to is simple and straightforward. It means following my duty of care. In acute [settings], you focus on biomedical signs, and you cannot always develop a relationship with the human being. In chronic settings, you have time to develop a professional/personal relationship. In long-term rehabilitation, you need to consider the human being more. It is more relaxing, working slower with patients. (Petra) This quote succinctly describes the attitude of the contemplators, who saw collaboration as optional and not suitable in some settings. The attitude was that practitioners have permission to assume professional power over their patients because of their professional status and knowledge. That is, they considered that professional relationships in the healthcare context start with uneven power relationships, where practitioners have more power than patients. When the participants were asked to rethink and democratize their relationships with patients, the implication was that patients had to be taken more seriously as people with a role to play in clinical decision making and self-management. In exploring collaboration, the participants were challenged to listen critically to patients and develop open dialogue with patients.

The Transformers The transformers trialled democratizing their relationships with

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patients; they were willing to challenge their use of professional power. Jocelyn, for example, became more attentive to interests and to her patients’ expectations of physiotherapy. She found that some patients had clear expectations and knew what they wanted. When comparing these with her own professional expectations and goals, Jocelyn experienced conflict. She described an incident with an 80year-old patient who could not carry her shopping home but otherwise was able to be fully independent. Jocelyn noted the decreased range of motion in her shoulder joint, and she wanted to work first on increasing range of motion and then on strengthening muscles. However, her patient was not interested in increasing range of motion (Box 15.5).

Box 15.5

Being a Transformer I could see that [this] patient was not interested in my plan. I thought this wasn't particularly functional [wanting to increase strength before increasing range of motion], but she was able to do everything: cook, clean and so on. The only thing she couldn't do was go shopping because she couldn't carry anything. So, that was really glaring in my face. This is what she wants to do. I am not sure if I always pick that up. (Jocelyn) In this situation, Jocelyn appeared comfortable to go with her patient's goals. Her decision was influenced by her patient's age. Had her patient been younger, she might have insisted on improving range of motion as well. Jocelyn made decisions in the context of her patient's age and function and with a critical stance to self. She was willing to reconsider, in this situation. However, generally speaking, Jocelyn was not content to allow patients to lead treatment plans unconditionally. Corinne displayed a capacity for critical self-reflection in relation to her issues around professional authority and power relations. Corinne had over 30 years of clinical experience, and her area of expertise was outpatient physiotherapy. She questioned her practice and viewed each treatment as a learning process for herself and her patients (Box 15.6).

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Box 15.6

Being a Transformer I want to learn from patients so that I can improve my own skills. I think that every treatment session is a learning session for me. I learn from my patients. (Corinne) Corinne learned to recognize that she was not the only expert or the professional who should know all the answers. She could appreciate that patients had relevant knowledge as well. Corinne learned to reframe herself as a facilitator of collaborative decision making. She not only transformed her approach to practice and her view of herself as a professional, but she also learned about practice as a collaborative transformation.

The Champions Participants who had operationalized collaborative decision making and endorsed the values of inclusion and power sharing were labelled champions or advocates of the critical social science approach. These participants were skeptical and critical of professional authority that was taken for granted and automatically assumed. Raymond, one of this group, saw himself as a scientist, a critical self-reflector and a patient collaborator (Box 15.7).

Box 15.7

Being a Champion Is physiotherapy a social science? To me it is, and my colleagues will hit me over the head. I think there are the arts and the sciences. It is somewhere between the two. You have to oscillate all the time to facilitate an outcome for the patient. So I have this pulling force in me all the time. I value the scientific and searching for the evidence, but I am worried about the patient. (Raymond) Raymond saw himself as integrating biomedical facts with patients’ perceptions of their healthcare needs and condition. He

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defined his practice as ‘doing qualitative medicine’. He recognized that a collaborative approach to decision making did not exclude propositional or scientific knowledge, but it also required nonpropositional knowledge to achieve emancipatory outcomes. Champions do not make decisions without continually checking their impact with individual patients; they regard patients as social, cultural and political human beings (Box 15.8).

Box 15.8

Being a Champion You cannot tell a teenager to stop smoking. You need to look at their social issues. I practice physiotherapy like that. First [I consider] scientific knowledge and then social beliefs and patient knowledge. (Raymond) In analyzing the interviews with the champion group, a number of factors that indicated participants’ capacity or inclination for participating in collaborative decision making were identified. These included:

▪ appreciating patients’ perspectives (e.g., fear, lack of knowledge), ▪ becoming self-aware of personal bias, ▪ actively providing opportunities for patients to participate, ▪ being willing to reconsider treatment choices, ▪ exploring options with patients, ▪ establishing reciprocal relationships (by being open and enabling patients to be open), ▪ facilitating a reciprocal process of teaching and learning from each other and ▪ recognizing clearly the values that inform decision making. 384

The champions in this study (Trede, 2008) used their human agency to facilitate change in their patients. They can be described as deliberate professionals (Trede and McEwen, 2016); they were aware of self, their patients and the context around them, they weighed up possibilities and made a decision together with their patients and shared responsibilities for the consequences of these decisions.

Chapter Summary In this chapter we have done the following:

▪ We discussed the new conditions, diverse interests and fluid roles and contexts of practitioners and patients and the complex processes that need to be meaningfully integrated in collaborative decision-making processes in these liquid times. ▪ We identified a series of questions for clarifying assumptions about decision making. ▪ We demonstrated the central importance of adopting a critical perspective on collaborative decision making. ▪ We illustrated various operationalizations of collaborative decision-making practices. Reflection Point 4 Can you see yourself as a practitioner in any of these prototypes? Where do you think students and experts fit into this set? What do you see as the implications for collaborative decision making?

References 385

Arnetz JE, Almin I, Bergström K, et al. Active patient involvement in the establishment of physical therapy goals: effects on treatment outcome and quality of care. Adv. Physiother.2004;6:50–69. Bauman Z. Liquid Modernity. Polity Books: Cambridge, UK; 2012. Charles C, Gafni A, Whelan T. Shared decisionmaking in the medical encounter: what does it mean? (or it takes at least two to tango). Soc. Sci. Med.1997;44:681–692. Edwards I, Jones M, Higgs J, et al. What is collaborative reasoning?. Adv. Physiother.2004;6:70– 83. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J. Gen. Intern. Med.2012;27:1361–1367. Floridi L. Hyperhistory and the philosophy of information policies. Philos. Technol.2015;25:129– 131. Habermas J. Knowledge and Human Interest. Heinemann: London, UK; 1972. Jones M, Grimmer K, Edwards I, et al. Challenges in applying best evidence to physiotherapy. Internet J. Allied Health Sci. Pract.2006;4. Lin GA, Fagerlin A. Shared decision making: state of the science. Circ. Cardiovasc. Qual. Outcomes. 2014;7:328–334. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ. Couns.2006;60:301–312. Matthias MS, Salyers MP, Frankel RM. Re-thinking shared decision making: context matters. Patient Educ. Couns.2013;91:176–179. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ.

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2012;345:e6572. Trede FV. A Critical Practice Model for Physiotherapy: Developing Practice Through Critical Transformative Dialogues. VDM Verlag Dr Müller: Saarbrücken, Germany; 2008. Trede F, Higgs J. Re-framing the clinician's role in collaborative clinical decision making: re-thinking practice knowledge and the notion of clinician– patient relationships. Learning Health Soc. Care. 2003;2:66–73. Trede F, McEwen C. Scoping the deliberate professional. Trede F, McEwen C. Educating the Deliberate Professional: Preparing for Emergent Futures. Springer: New York, NY; 2016.

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16

Ethical Reasoning Ian Edwards, Clare Delany

CHAPTER AIMS The aims of this chapter are to: ■ outline the Ethical Reasoning Bridge model, ■ explain the relationship between normative and nonnormative ethics and ■ present the relationship among individual ethical reasoning, social ethical reasoning and moral agency.

KEY WORDS The Ethical Reasoning Bridge Normative and nonnormative ethics Individual and social ethical reasoning Moral agency

ABBREVIATIONS/ACRONYMS ER Bridge Ethical Reasoning Bridge

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ACFI Aged Care Funding Instrument

Introduction Ethics is essentially concerned with how people should conduct themselves in particular social roles and practices (Purtilo, 2005). In health care, ethics has to fulfil two quite different and sometimes competing tasks (Komesaroff, 2008). First, it has a regulatory role in ensuring that widely agreed-upon and expected standards of professional behaviour, including the ethical conduct of healthcare practitioners, are adhered to. These ethical standards are expressed in professional codes of conduct, compliance with which is overseen by professional associations and boards (Hugman, 2005). A second less visible task of ethics, as suggested by Komesaroff (2008, p. xiii), is subversive in that it questions the prevailing values and conditions in which an ethical issue arises and is played out and the assumptions and motives, which influence people (healthcare practitioners and nonpractitioners alike) to act and behave as they do. This second task of ethics also seeks to understand a person's moral agency (or capacity to act). And this involves an understanding of the choices - or lack of them – that people have, or perceive that they have, in various situations or dilemmas (Edwards et al., 2011). Although both share the care of the patient as an ultimate goal, the first task of ethics is normative as it is concerned with ‘what ought to happen’, and the second is nonnormative and focusses on ‘what actually happens’. Between ‘what ought to happen’ and ‘what actually happens’ in the care of the patient, there is a moral landscape that is often uncertain and difficult for practitioners to negotiate. It is a terrain that is continually being reshaped by changing societal values, patterns of healthcare practice and funding models (Delany et al., in press; Edwards, 2016). Ethical reasoning refers to the thinking and decision-making processes by which the practitioner evaluates what takes place between ‘what ought to happen’ and ‘what actually happens’ for the purpose of an ethical response. In the previous edition, we presented an ethical reasoning and decision-making model called the Ethical Reasoning Bridge (ER

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Bridge) (Edwards and Delany, 2008). This model was originally derived from research of the decision making of expert physical therapists, which was described as dialectical insomuch as it moved between, and expressed, different conceptions of knowledge (Edwards et al., 2004). The ER Bridge model aims to assist the ethical problem solver to both recognize and engage with the different conceptions of normative and nonnormative ethics. On the normative ethics side of the ER Bridge (Fig. 16.1), the professional world of the healthcare practitioners, are universal ethical principles (beneficence, nonmaleficence, respect for autonomy and justice – Beauchamp and Childress, 2009) that have traditionally underpinned professional codes of conduct. It has been widely argued that this approach to ethics, also known as ‘third-person’ ethics (Mattingly, 2012), expresses the deductive and rationalist methods of scientific problem solving because it privileges the application of universal or generalizable rules and principles in predicting what impartial ‘outcomes’ should be in particular ethical dilemmas (Callahan, 2003; Fox, 1994; Komesaroff, 2008; Mattingly, 2012; MacIntyre, 2007).

FIG. 16.1 The Ethical Reasoning Bridge.

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On the nonnormative side of the ER Bridge, the site of others (patients, carers and the community), is a method of inquiry called narrative reasoning that is concerned with understanding the lived experience of people, their sense of identity and their moral strivings in particular contexts. Narrative reasoning has as its theoretical basis that we are ‘self-interpreting creatures’ (Taylor, 1985b) who make sense of our lives and form identities, and therefore purpose, via the construction (and ongoing ‘reconstruction’) of our narratives (Ricoeur, 2006). Understanding what is morally at stake for people in their moral struggles in various contexts has been termed first-person ethics (Mattingly, 2012) and requires a recognition of multiple and socially constructed realities in our relationships with others (see Fig. 16.1). The ER Bridge model of ethical reasoning, as a means of inquiry and analysis, is not unlike a mixed-methods research approach. A hallmark of mixed-methods research is that the different paradigms of inquiry, somewhat counterintuitively, inform each other during the conduct of the research and not just at its conclusion when making sense of findings (Burke et al., 2007). We would make the same kind of claim with respect to the ER Bridge: namely, that moving between and engaging different paradigms of inquiry and reasoning - crossing ‘the bridge’ – yields richer insights regarding the nature of the ethical issue and the relationships between various factors and social actors involved in it than via one method alone (Edwards, 2016; Swisher et al., 2012). In this revised chapter, we wish to reassert the relevance of the ER Bridge model and argue that it has utility for the ethical problem solver in being able to span a morally diverse and changing healthcare terrain. Like any model, it aims to represent important concepts or ideas and their relationships. However, we acknowledge a need to further explain aspects of the ER Bridge model that were either unelaborated or unexplained in the previous edition. In this chapter, we focus on healthcare practitioners who, in intentionally crossing and recrossing the ER Bridge, are able to nurture moral agency in themselves and others. We structure this focus by: a) discussing the rationale for the relationship between normative and nonnormative ethical reasoning, arguing that it is a mutually informing interaction; b) describing how, when the practitioner ‘crosses’ and ‘recrosses’ the ER Bridge, there is both an

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individual and a social reasoning process; and c) examining the relationship between the moral identity and moral agency of practitioners as a means of discovering ethical possibilities, with others, in difficult and ambiguous ethical scenarios.

The Ethical Reasoning Bridge Normative and Nonnormative Ethics Students in the various healthcare disciplines are commonly taught versions of patient interviewing and physical examination (previously known as subjective and objective assessments) that are relevant to the ‘diagnostic’ and therapeutic practices of their discipline. Healthcare students have often learned, whether educators intended it or not (Shepard and Jensen, 1990), that ‘to be objective’ and to avoid ‘subjective bias’ are the preeminent perceptual postures of the problem solver. The desire for ‘objectivity’ has also permeated ethical reasoning models in health care (Callahan, 2003; Komesaroff, 2008). The hegemony of data that is ‘objective’ over that which is ‘subjective’ is gradually changing as the utility of collaborative goal setting and incorporating the ‘patient's point of view’ is increasingly valued (Reunanen et al., 2016). Notwithstanding this, ‘being objective’ remains relevant for particular instrumental problem solving and procedural tasks in health care. However, it is not the clear-cut problem solving posture that it might seem, particularly if one applies the notion to one's dealing with others (Mattingly, 2014; Zahavi, 2005). Thomas Nagel (1989), in his philosophical treatise, ‘The view from nowhere’, stated that the problem of objectivity was, ‘how to combine the perspective of a particular person inside the world with an objective view of that same world, the person and his viewpoint included’ (Nagel, 1989, p. 3). Even with his particular interest in the physical sciences and proclivity towards ‘objectivity’, Nagel conceded that for a person who is trying to make sense of what he or she sees before him or her, pure ‘objectivity’ is not possible, because in looking at the world, ‘However often we may step outside ourselves, something will have to stay behind the lens, something in us will determine the resulting picture’ (p. 68). Nagel therefore proposed the need for a ‘double vision’, where we see the

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world ‘from nowhere’ (unbiased and objective) while at the same time we see the world ‘from here’ (our own perspective) (p. 86). To see the world ‘from nowhere’, however, is to arguably neutralize both our own and others’ perspectives, neither achieving objectivity nor further insight into understanding how either party experiences the world (Volf, 1996). Reinforcing this idea, Gallagher and Zahavi (2007) state (we have added the terms ‘objective’ and ‘subjective’): There is no pure third-person (objective) perspective, just as there is no view from nowhere. … This is not to say that there is no thirdperson (objective) perspective, but merely that such a perspective is exactly a perspective from somewhere … it emerges out of the encounter between at least two first-person (subjective) perspectives; that is, it involves intersubjectivity (Gallagher and Zahavi, 2007, p. 40). Intersubjectivity, as an encounter between different perspectives, supports the idea that we see the world not as a view from nowhere but from ‘here’ (our own) and from ‘there’ (others’ perspectives) (Taylor, 1985a). This is a rationale for the ER Bridge. The practitioner crosses from ‘here’ (his or her own professional and/or personal perspectives) to ‘there’ (the perspectives of others – patients/carers/other healthcare workers). And so, although the theoretical underpinnings on the ER Bridge relating to research paradigms may suggest a dichotomy between objectivity and subjectivity, we propose that it is conceptually more helpful to think of this ‘crossing’ in terms of reasoning with either a normative or a nonnormative intentionality. ‘Intentionality’ is a term from phenomenology (Larkin et al., 2011). It does not refer to a practical intention to ‘do something’ but instead refers to the proposition that we have a conscious relationship with an object – externally or in mind or memory – about which we interpret and develop meaning (Greenfield and Jensen, 2010, p. 1190). For example, when engaged in diagnostic or procedural clinical reasoning, the healthcare practitioner adopts what might be termed a ‘normatively oriented intentionality.’ That is, when listening to and examining a patient, the practitioner looks for what he or she already recognizes, in terms of what he or she considers as significant towards forming some kind of diagnosis or

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other evaluation of the patient. A doctor looks, therefore, for the signs and symptoms of a particular disease entity. This leads to a categorization and ordering of the features of a presentation, with an emphasis on recognizing what is known and what – in a normative sense – is expected or ought to be found (Edwards et al., 2011; Kahneman, 2011). A normative intentionality with respect to ethical reasoning would see a similar framing and categorizing of an ethical scenario or dilemma via certain recognizable features or categories – at least to the practitioner – in terms of injunctions of a code of conduct or particular ethical principle (Callahan, 2003). Read Case Study 16.1 to see how physiotherapy student, Theresa, initially frames the ethical dilemma involving her patient Coral.

Case Study 16.1

Ethical Reasoning Theresa is a final-year physiotherapy student on clinical placement at an aged care residential facility. This facility offers a range of healthcare services to both its residents and its home-based clients, including physiotherapy, podiatry, occupational therapy, dietetics, speech pathology, social work and nursing. Coral is a 62-year-old woman who had a right-sided stroke some 9 months previously that left her with left-sided hemiparesis. Before the stroke, she lived independently with her husband of 35 years and did most of the housework. She also took care of her two young grandchildren (3 and 5 years of age) on a regular basis and was an active member at her local Rotary club. She had been assessed by an Aged Care Assessment Team (ACAT) and deemed to be ‘high care’ using the Resident Classification Scale. Based on this assessment, and the fact that her husband, John, was not able to assume the responsibility of caring for her at home, Coral was admitted into this care facility. It had been a difficult decision about which both Coral and John were still grieving. The ACAT assessment had also determined that Coral needed two heavy ‘assists’ and a lifter to get her in and out of the bed. However, Coral had also engaged in rehabilitation at the facility, and there were slow but demonstrable changes towards more

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independence and increased function. Theresa (the physical therapy student) was asked to visit Coral to provide physiotherapy treatment. After her assessment, she concluded that although it was true that Coral still required some assistance, it was clear she no longer needed the lifter to transfer in and out of the bed. She also found that Coral was teary and emotional, especially when she talked about her life before the stroke. She felt the stroke had rendered her useless, and she felt like a burden to her family now. She wanted to get better but felt it was better for everyone if she stayed in the residential facility. John was a supportive husband and carer. He was also present at this session, and he, too, became emotional when recalling their life together before her stroke. However, he also expressed anger and frustration at the time and delay it took for a lifter to be organized every time Coral wanted to get out of bed. John said that this just seemed to further reinforce how Coral felt about herself. In addition to physiotherapy, Coral was also receiving visits from occupational therapy and speech pathology. In a case meeting with the nursing home administrator, Theresa, the occupational therapist and speech pathologist, stated that Coral was progressing quite well in particular areas of function and may need another assessment by ACAT. The administrator was reluctant to proceed. To Theresa's surprise, Bev, her physiotherapy clinical supervisor, also seemed to drag her feet in the discussion. Later, Bev discreetly told Theresa about the nursing home's precarious financial position. Not needing a lifter would change Coral's care level and therefore reduce the funding they were receiving for Coral. Bev admitted that this was not an ideal situation, but they were having to maximize funding opportunities with respect to the residents, wherever possible, to keep their jobs and the facility open. It was a difficult balance, she explained. Theresa is an inexperienced practitioner but enters this scenario as someone with ‘fresh’ eyes. From her professional training, she already has acquired a strong sense of the philosophy of physiotherapy, which is to assist people to maximize their physical capacities and functioning for better participation in the activities that they value in their lives. Theresa judges that this professional obligation is being compromised in Coral's overall care. It is because she has also acquired normative ethical knowledge in

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learning about ethical principles and professional codes of conduct that Theresa is sensitized to what she has witnessed in Coral and John's situation, recognizing this as being unethical. More specifically, she is able to say that respect for Coral's autonomy or, to put it another way, Coral's right (together with John) to make significant decisions in her own health care is not being upheld. A nonnormative intentionality concerns ‘recognition’ of another kind. It focusses less on the ‘what’ of an ethical problem and more on the motives and choices of those involved in it. Theresa has noted the apparent frustration of participants in this scenario that arises for different reasons. Coral is feeling useless and that she is a burden to everyone. Her partner, John, is angry and frustrated because of the strict implementation of the regime concerning the use of the lifter. He believes that it is demeaning to Coral and further contributes to her sense of being a burden to everyone. Theresa's physiotherapy clinical supervisor, Bev, does not dispute Theresa's (or John's) analysis of the situation. She does provide, in an embarrassed, almost defeated manner, an explanation of why things are currently as they are. What was initially a definable ethical issue in normative terms now seems to be more like a spider web in which people are each caught and held between competing interests.

The Social Formation of Ethical Reasoning On each side of the ER Bridge are represented relationships between individuals and communities (see Fig. 16.1). There is a relationship between individual practitioners and their own professional communities of practice. Patients and carers are also members of the various contexts and communities in which they live their lives. Finally, there is also a relationship between healthcare practitioners and the workplaces or institutions in which they work. This leads to the idea of individuals as members of various cultures, each one having a shared set of beliefs and practices, however explicitly or implicitly these may be recognized. We focus here on healthcare practitioners in workplace cultures and the formation of ethical behaviour in these cultures. The ethical reasoning of an individual is always constructed with ‘reference to some defining communities’ (Mattingly, 2014, p. 22). Taylor (1989)

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illustrates the dialectical nature of the individual and the social in the formation of moral identity when he writes ‘one cannot be a self on one's own’ (p. 36). Ethical reasoning is likewise both an individual and a social (or public) phenomenon. A number of healthcare scandals have recently been reported (Box 16.1) where formal inquiries into what went wrong later found that it was not the actions of one particular individual or practitioner that led to the malpractice. Instead, these inquiries found, in each example, a complicity among practitioners that was termed by one inquiry as ‘a culture of acceptance’ and by another as ‘systemic failure’. Practitioners had either become resigned to current practices or had become desensitized to their ethical obligations, allowing them to turn ‘a blind eye’ to what was going on.

Box 16.1

Ethical Scenarios and ‘Cultures of Acceptance’ ‘Bloodgate’ ■ http://www.smh.com.au/rugby-union/union-news/doctorashamed-of-role-in-fake-blood-scandal-20100825-13qwe.html ■ Bacchus Marsh Community Hospital – 11 preventable neonatal deaths ■ http://www.abc.net.au/news/2016-06-08/review-finds-11-babydeaths-avoidable-at-djerriwarrh-health/7492030

Incorrect results for prostate cancer ■ http://www.abc.net.au/news/2016-04-03/cancer-pathologyblunder-false-positive-sacking/7295132 ■ Underdosing of chemotherapy for cancer patients ■ http://www.abc.net.au/news/2016-10-31/chemotherapyinquiry-to-hear-about-culture-of-acceptance/7978548

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Theresa decides to share her sense of ethical distress with a mentor, while maintaining confidentiality (see Case Study 16.2).

Case Study 16.2

Truth and Ethics Theresa angrily expresses her feelings about her experience, ‘The truth needs to be told about this situation!’ Her friend listens and responds, ‘Yes, but whose truth?’ ‘What do you mean whose truth?’ replies Theresa, suppressing a certain agitation at the question. ‘Well, the way you are talking suggests that this is only one ‘truth’ or interpretation of what is happening when in fact there are multiple ‘truths’ in this scenario. Each person involved here has a particular perspective that influences their actions’. ‘But surely’ exclaims Theresa, ‘the only perspectives that really count are those of Coral and John, and they are the ones we should be really listening to and acting upon’. ‘You may well be right’ replies the friend, ‘but the fact is that this is not happening, regardless of whether it ought to. And so, although I agree with you that this resident's autonomy is not being fully respected, in order for there to be any meaningful change in this place, there has to be an understanding of everyone's choices in the situation – real or perceived – and who or what constrains those choices. Theresa, you have found yourself in ‘a culture of acceptance’. ‘What do you mean by ‘culture of acceptance?’ asks Theresa, calling upon her reserves of patience. ‘Just that this ethical issue you have come across requires the assent – tacit or otherwise – and complicity of more than one person for it to be perpetrated. For there to be any change, you are going to have to understand why this “culture of acceptance” has come into being. Cultures tend to “happen” over time without explicit decision making or intention. Getting people to speak about their particular situation and how they see the situation helps open up this “culture” for examination. Sharing your dilemma with someone else – like me – was a good start’. ‘And another thing, you could also find out more about the

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Aged Care Funding Instrument (ACFI) and how it is intended to work. I can assure you that what you are witnessing is not just happening where you are doing your placement. The claims made by aged care units on the high care needs of residents1 have exceeded budgetary expectations. After you do that, you might be able to work out what other conversations and actions are possible. If you are still interested in working in the aged care field, you are going to need to come to grips with the way in which funding models and budgetary pressures influence behaviour and practice’.

1See

https://agedcare.health.gov.au/tools-and-resources/aged-carefunding-instrument-acfi-reports Theresa's conversation with her mentor raises the notion of moral agency or a person's capacity to act for the good in a situation. In terms of the Ethical Reasoning Bridge, by paying attention to ‘what actually happens’, as suggested by her mentor, via a self-expressed narrative (or lived experience), rather than via a priori normative ethical principles, Theresa begins to recognize and then exercise her moral agency. Ricoeur (2006) expresses this as being able to connect oneself to an experience and one's own actions in it and in doing so make oneself the ‘author’ of an ethical response. Although it is still not clear to Theresa what she ‘ought to do’ in this situation, she now understands that there are also other ‘moral agencies’ to be considered in this scenario, each with a willingness or capability to act that is yet to be determined. Theresa takes what she has learned from adopting a nonnormative intentionality back to the ‘site’ of her professional knowledge base and decision-making responsibilities: the side of the ER Bridge where ‘what ought to happen’ is waiting for a response. But this normative ‘what ought to happen’ does not necessarily now offer the same conception of the scenario that it did before the first crossing of the ER Bridge. It is now less amenable to a prescriptive and individual solution, and more requires a negotiated and cultural change, in concert with others. It is also a necessary step, rather than an end in itself, because it is ultimately important ‘to know not about actuality but about possibility’ (Lear,

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2006, cited in Mattingly, 2014, p. 28 – our emphasis). Possibilities of ‘what is the good’ in a situation may arise from among a range of different perspectives and interests. The capability theory of justice proposed by Amartya Sen (2009), and further developed by Martha Nussbaum (2011), proposes that it is not sufficient for healthcare professions and practitioners to provide the conditions – via universal ethical principles or moral rules – by which the freedoms, personal autonomy and right to fairness for patients and others are respected. We need to be equally concerned with people's actual capabilities to exercise or act upon these things towards what they consider as important for their lives (Nussbaum, 2011; Sen, 2009). And this requires a public form of ethical reasoning and decision making that allows people to understand and act upon what they value in given situations (Sen, 2009).

Moral Identity and Agency The question remains: How does a healthcare practitioner generate moral agency to act for the good in a workplace culture mediating ethical misconduct, where the wielding of power and rank by some persons over others may largely extinguish it? In such situations, the practitioner's capacity to critically reason and then act cannot be separated from his or her sense of a moral self (Ruitenberg, 2011). How we understand ‘our moral self’ (or moral identity), according to the ancient Greek philosopher Aristotle, will determine the extent to which we can ‘act for the good’ (Mattingly, 2014). We, therefore, turn to a brief discussion of contemporary virtue ethics where the question concerning ‘who we are’ has become ‘how we claim to know who we are’ (Frank and Jones, 2003). Two directions have arisen in the scholarship reinterpreting Aristotle's philosophy. One direction included philosophers such as Martin Heidegger, Alasdair MacIntyre, Iris Murdoch, Martha Nussbaum, Paul Ricoeur and Charles Taylor who, although not homogenous in their explanations of morality, nevertheless share a claim that a moral decision or action cannot be determined through some universal set of rules, procedures or reasoning processes derived from an Archimedean or ‘third-person position’. The second direction is found in poststructuralism and the work of

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Foucault and Derrida (among others), who, in large part, agree with the first group discussed earlier, that what is ‘moral’ in a society is ‘dependent upon the cultivation of virtues that are developed in and through social practices’ (Mattingly, 2012, p. 164). Foucault examined the social practices through which people create (or have created for them) their sense of who they are (Frank and Jones, 2003, p. 179). In doing so, he uncovered the surreptitious, often damaging and unjust ways that moral claims were made about those with mental health problems, those who were prisoners and (particularly relevant for medicine) those who were considered ‘deviant’, all as part of ‘ “rehabilitative” practices that constructed those very same categories and created new forms of knowledge that defined them’ (Mattingly, 2012, p. 163); the so-called shaping of ‘docile bodies’ under the ‘clinical gaze’(Foucault, 1991). The overuse of psychotropic medication has been likened to this (De Bellis, 2006). He further demonstrated the role of social structures and discourse in shaping what is even understood as moral. And, for Foucault, this inevitably involved the exercise of power (Frank and Jones, 2003). In his later work, Foucault drew on Aristotelian ideas to offer a recognition of moral practices that he termed ‘self-care’ or ‘self-cultivation’ (of virtue) but warned that it can end up as ‘no more than (or less than) practices of normalization of a particular regime of truth’ (Mattingly, 2012, p. 173). And so, for Foucault, firstperson ethics is the subjective work produced by (moral) agents to conduct themselves in accordance with their inquiry about what a good life is (Fassin, 2012, p. 7), and human agency is defined in terms of ‘one's awareness of the nature of one's conformity (or not) to certain discursive practices rather than the efforts of particular individuals in particular circumstances’ (Mattingly, 2012, p. 175). Others have questioned whether Foucault's conclusions regarding the power of discourse to subjugate people collectively in particular social practices need also mean rejecting the idea of an individual moral agent who is able to develop a ‘hermeneutic understanding of truth as self-interpretations’ (Taylor, 1985b, p. 385). Such a hermeneutic-oriented, first-person ethics draws on the phenomenological construct of intentionality (discussed earlier), where our understanding of reality ‘out in the world’ presents itself to us only in our engagement with it (Mattingly, 2012). Aristotle believed that ‘the self’ is ‘grounded in capabilities for experiencing

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the world’ (Baracchi, 2008, p. 2). Similarly, Ricoeur (1992) has argued that our moral identity is a narrative identity, where we make sense of ourselves only in and through our involvement with others and through the exercise of our capabilities. We do not simply enact a role, function or practice that has been assigned to us (in contrast to Foucault's ideas) but are capable of initiating new actions and choices (Ricoeur, 2006). In summary, and without fully reconciling these two broad directions in virtue ethics, a view of moral identity and agency arises in which the power of discourse to subjugate people and the way they think, as outlined by Foucault, is acknowledged. That is, social practices – of which health care is one – are inevitably and thoroughly permeated by the use of power by some over others (see De Bellis, 2010; Parker, 2007, for discourses in aged care in Australia). However, at the same time, we concur with Ricoeur, Taylor, Sen and Nussbaum that individuals are capable of selfinterpretation and, arising from that, therefore capable of choice and action. In Case Study 16.3, Theresa speaks once more with her clinical supervisor, Bev. Although she does not have much power as a student, in either the relationship or the aged care facility, she does exercise the moral agency that she has.

Case Study 16.3

A Second Conversation Between Theresa and Bev ‘Bev, thanks for agreeing to meet with me once more. I have looked at the way the ACFI works, and I can understand how, from a funding perspective, it may be better financially for the unit to maximize impairments of residents. However, I am still concerned that this approach is having a negative effect on residents. In particular, Coral's activity and participation capabilities are being held back by the reluctance to review the use of a lifter for every transfer. I find it really hard to face John and justify its use, when he is so frustrated and angry about it, and when I really think that there is potential for her to be able to transfer safely without it’. ‘I have been here for 11 years now, Theresa. Over that time, I have seen how funding to run this place became more and more

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precarious. It got to the stage where the organization was laying off staff and our positions were in jeopardy. My partner and I still have a mortgage – it wasn't easy. I think with the ACFI model, we were thrown something of a lifeline. And maybe there is now some kind of overly strong grasp on this lifeline – I don't know. I will say that I hadn't realized quite how upset John was about Coral and the lifter. You must not have a very good opinion of me.’ ‘Well, I think what worries me, Bev – apart from Coral and John's situation – is that I am discovering an unwanted truth about the extent to which I am able to practice my profession in an ethical way. And that is, a growing realization that other things outside my own knowledge, skills and values influence what I do as a physiotherapist with people, more than I would have ever believed’. ‘You do learn not to be naïve in this work, Theresa. But … on the other hand, I don't want to lose sight of why I entered aged care work either. I think that there may still be some in our organization who remain caught in our traditional identity as a nursing home and aren't willing to recognize the more recent focus on the rehabilitative work we undertake with residents – you know, the idea that they can actually improve. I think we should get another review done of Coral and her level of care. I will have to speak with June – she has lots of pressures on her – but the satisfaction of the residents and families is an important part of our ongoing viability – and accreditation – too. I am not sure, but maybe we need to have some sort of in-service staff session about these issues’. In her discussion with Bev, Theresa is able to name the complicity that enables this ethical scenario to continue, with its effects on residents such as Coral and her partner, John. From being tacit and unexpressed as an ethical issue, it begins to be articulated. To that extent, this is a movement towards public or social ethical reasoning. The exercise of moral agency by one party (student Theresa) leads, in this case, to the facilitation of moral agency in another, her clinical supervisor, Bev. Although there is usually a significant power and rank differential between a student and supervisor, nevertheless, it is one among others in this scenario – for example, between John and the nursing staff, between Bev and

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her manager, June. We want to suggest that the power in such relationships is not so fixed that capability for moral action is not possible. Theresa's overture to Bev may not always ‘work’ as a conflict resolution ‘method’ or lead to a particular outcome. Occasionally workplace cultures can become so entrenched in ethical misconduct and resistant to change that moral agency must take the form of becoming a whistleblower.i However, our focus here is in recognizing and working in less extreme cases. In the way that Theresa approaches this conversation, we see that it does provide space for Bev to engage in self-interpretation and consider her own moral identity and choices. And from this, Bev may, in turn, choose to similarly converse with other staff, including her boss, June, about Coral and John's situation. A single conversation does not represent a complete resolution of this ethical dilemma. However, it is a step toward ‘critiquing’ a culture. Possibilities will need to be explored by the various parties at the local level (i.e., in addressing Coral and John's situation); at the institutional level (i.e., recognizing what is happening at the facility and engaging staff perspectives regarding what may be possible as a response); and finally, at wider policy levels (i.e., how the company running this unit together with the wider Aged Care industry, and professional associations, and providing feedback to government regarding the efficacy of funding models such as ACFI). Such actions will only be achieved when those involved in this scenario realize their own moral agency. The ER Bridge (see Fig. 16.1) represents how one's moral identity, as an individual, is shaped in and by our relationships with others in the various communities (practice, workplace and societal) to which we belong. Moral agency is therefore partly a function of how we see or interpret ourselves in relation to others in these communities. Individuals have capabilities to act ‘for the good’ in their communities – of whatever kind – to the point where a community might then reexamine their own collective sense of identity and purpose.

Chapter Summary In this chapter, we have outlined an ethical reasoning model termed the Ethical Reasoning Bridge. This model aims to assist the

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practitioner to negotiate the sometimes difficult moral terrain between the normative ‘what ought to happen …’ and nonnormative ‘what actually happens…’. When the practitioner ‘crosses’ the ER Bridge, he or she explores the relationship between normative ethics and nonnormative ethics such that the value of each is further enriched by the ethical insights provided by the other. We have also outlined how, in crossing the ER Bridge, there is also a movement between individual ethical reasoning and social or public ethical reasoning. Social reasoning allows for the examination of relations between various parties – sometimes presenting as cultures – as factors that influence or constrain choice. Understanding people's choices (or their perception of them) helps understand their sense of moral agency. Finally, we have proposed that ethical reasoning cannot be separated from the moral identity of the problem solver. One's moral identity is formed, in part, through the relationships an individual has with others, and this, in turn, influences a sense of moral agency.

Reflection Point 1 Think of an ethical scenario that you have either observed or been involved in at your workplace (or on placement). 1. How might using the ER Bridge, with normative and nonnormative ethical analyses of the case, inform your response to both the ethical issue and the other persons involved? 2. What communication skills might you need for your intended response to become an action? 3. How does your ethical response relate to your professional identity and role?

References Baracchi C. Aristotle's Ethics as First Philosophy. Cambridge University Press: Cambridge, MA;

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2008. Beauchamp TLC, Childress JF. Principles of Biomedical Ethics. sixth ed. Oxford University Press: New York, NY; 2009. Burke Johnson R, Onwuegbuzie A, Turner L. Toward a definition of mixed methods research. J. Mix Methods Res.2007;1:112–133. Callahan D. Principlism and communitarianism. J. Med. Ethics. 2003;29:287–291. De Bellis A. Behind open doors: a construct of nursing practice in an Australian residential aged care facility. [PhD thesis; Flinders University, Adelaide, VIC] 2006. De Bellis A. Australian residential aged care and the quality of nursing care provision. Contemp. Nurse. 2010;35:100–113. Delany C, Edwards I, Fryer C. How physical therapists perceive, interpret and respond to the ethical dimensions of practice: a qualitative study. Physiother. Theory Pract.2018. Edwards I. The moral experience of the patient with chronic pain. van Rysewyk S. Human Meanings of Pain. Springer International Publishing: New York, NY; 2016:195–210. Edwards I, Delany C. Ethical reasoning. Higgs J, Jones MA, Loftus S, et al. Clinical Reasoning in the Health Professions. third ed. Elsevier: Edinburgh; 2008:279–289. Edwards I, Delany CM, Townsend AF, et al. Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice. Phys. Ther.2011;91:1653–1663. Edwards I, Jones MA, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys.

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Ther.2004;84:312–335. Fassin D. Introduction: toward a critical moral anthropology. Fassin D. Toward a Critical Moral Anthropology. Wiley-Blackwell: Oxford, UK; 2012:1–17. Foucault M. Discipline and Punish. Penguin Books: London, UK; 1991. Fox R. The entry of U.S. bioethics into the 1990's: a sociological analysis. Dubose ER, Hamel R, O'Connell LI. A Matter of Principles? Ferment in US Bioethics. Trinity Press International: Valley Forge, PA; 1994:21–71. Frank A, Jones T. Bioethics and the later Foucault. J. Med. Human.2003;24:179–186. Gallagher S, Zahavi D. The Phenomenological Mind: An Introduction to Philosophy of Mind and Cognitive Science. Routledge: London, UK; 2007. Greenfield BH, Jensen GM. Understanding the lived experiences of patients: application of a phenomenological approach to ethics. Phys. Ther.2010;90:1185–1197. Hugman R. New Approaches in Ethics for the Caring Professions. Palgrave Macmillan: New York, NY; 2005. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux: New York, NY; 2011. Komesaroff P. Experiments in Love and Death: Medicine, Postmernism, Microethics and the Body. Melbourne University Press: Melbourne, VIC; 2008. Larkin M, Eatough V, Osborn M. Interpretative phenomenological analysis and embodied, active, situated cognition. Theory Psychol.2011;21:318–337. MacIntyre AC. After Virtue: A Study in Moral Theory. third ed. University of Notre Dame Press: Notre

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Dame, IN; 2007. Mattingly C. Two virtue ethics and the anthropology of morality. Anthropol. Theory. 2012;12:161–184. Mattingly C. Moral Laboratories: Family Peril and the Struggle for a Good Life. University of California Press: Oakland, CA; 2014. Nagel T. The View From Nowhere. Oxford University Press: New York, NY; 1989. Nussbaum M. Creating Capabilities: The Human Development Approach. The Belknap Press of Harvard University Press: Cambridge, MA; 2011. Parker D. The discourses of death and dying in residential aged care facilities in Australia. [In: Abstracts Supplement, DDD8: The Social Context of Death, Dying & Disposal Conference 2007. DDD8: 8th International Conference on the Social Context of Death, Dying and Disposal, 12–15 September, Bath, UK] 2007:S68. Purtilo R. Ethical Dimensions in the Health Professions. fourth ed. Saunders: Philadelphia, PA; 2005. Reunanen MA, Talvitie U, Jarvikoski A, et al. Client's role and participation in stroke physiotherapy encounters: an observational study. Eur. J. Physiother.2016;18:210–217. Ricoeur P. Oneself as Another. University of Chicago Press: Chicago, IL; 1992. Ricoeur P. Capabilities and rights. Nebel M, Sagovsky N. Transforming Unjust Structures: The Capability Approach. Springer: Dordrecht, The Netherlands; 2006:17–26. Ruitenberg C. The empty chair: education in an ethic of hospitality. Philos. Educ.2011;28–36. Sen A. The Idea of Justice. The Belknap Press of Harvard University Press: Cambridge, MA; 2009. Shepard K, Jensen G. Physical therapist curricula for

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the 1990's: educating the reflective practitioner. Phys. Ther.1990;70:566–577. Swisher LL, van Kessel G, Jones MA, et al. Evaluating moral reasoning outcomes in physical therapy ethics education: stage, schema, phase, and type. Phys. Ther. Rev.2012;17:167–175. Taylor C. Philosophy and the Human Sciences: Philosophical Papers, 2. Cambridge University Press: Cambridge, MA; 1985. Taylor C. Connelly, Foucault, and truth. Polit. Theory. 1985;13:377–385. Taylor C. Sources of the Self: The Making of the Modern Identity. Harvard University Press: Cambridge, MA; 1989. Volf M. Exclusion and Embrace: A Theological Exploration of Identity, Otherness and Reconciliation. Abingdon Press: Nashville, TN; 1996. Zahavi D. Subjectivity and Selfhood: Investigating the First Person Perspective. MIT Press: Cambridge, MA; 2005. iFor

example, Bundaberg Hospital: http://www.abc.net.au/news/2005-06-23/whistleblower-nursefronts-bundaberg-hospital/1599220

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17

Shared Decision Making in Practice Cindy Costanzo, Joy Doll, Gail M. Jensen

CHAPTER AIMS The aims of this chapter are to: ▪ identify key attributes of shared decision making (SDM) in practice, ▪ recognize organizational characteristics that support and facilitate SDM and ▪ describe practice strategies that lead to successful outcomes when engaged in SDM.

KEY WORDS Shared decision making Decision making Interprofessional teams

ABBREVIATIONS/ACRONYMS

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EHR Electronic health record IPE Interprofessional education IPCP Interprofessional collaborative practice IPDAS International Patient Decision Aids Standards Collaboration IP-SDM Interprofessional Shared Decision Making SDM Shared decision making

Introduction Health and well-being rely on the ability of a patient to make good decisions every day and over time. Healthcare providers often express frustration by the lack of engagement patients hold in the healthcare process and their own well-being. Yet healthcare systems and cultures clearly do not consistently support collaborative decision making of healthcare team members with patients. Shared decision making (SDM) offers an avenue to address the disconnects in care by engaging patients in collaboration with healthcare professionals in making informed healthcare decisions. In addition to identifying and describing the processes and best practices of SDM, the chapter will discuss the importance of organizational culture in the influence of the adoption and sustainability of SDM. In addition, SDM models, measurement tools and decisional aids that augment SDM in practice will be shared. This chapter promotes the use of interprofessional, team-based practices and a patient-centred SDM model to ultimately improve clinical outcomes of care.

Shared Decision Making Historically, decision making between healthcare professionals and patients has followed three definitive models: paternalism, consumerism and SDM (Fig. 17.1). A paternalistic model occurs when a provider or healthcare team makes the primary decisions and choices for the patient. A consumerist informative model occurs when the consumer makes a decision without involvement of a provider or healthcare team (Charles et al., 1997). SDM occurs with

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the involvement of patients, providers and interprofessional team members in the decision-making process. SDM is defined as ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences’ (Barr et al., 2014).

FIG. 17.1 Patient decision-making approaches.

SDM is best practice and should be mainstreamed, but its implementation and execution continue to be challenging (Müller et al., 2016). Informed consent, informed choice, consumer rights, patient-centred care and chronic illnesses with a lifetime management approach have accelerated the shift from the once dominant paternalistic approach to SDM (Charles et al., 1997). SDM provides a forum for the healthcare team to involve the patient and family as part of the team. Today's complexity of care reinforces the need for SDM and requires that the interprofessional team become adept at utilizing this approach. As health care moves towards interprofessional collaborative practice, it is critical that patients and families are valued members of this team (Interprofessional Education Collaborative, 2016).

Attributes of Shared Decision Making In SDM, the perspectives of the patient and/or family are valued as they collaborate with the healthcare team to make decisions about care (Interprofessional Education Collaborative, 2016). For SDM to be successful, several important actions are required. In SDM, interprofessional team members and patients must acknowledge that a decision should be made utilizing the best evidence, are mutually informed with an understanding of the decision's risks and benefits, hold a period of deliberation and incorporate the

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patient's values and preferences as the team and patient arrive at a mutually agreed-upon care plan (Charles et al., 1997; Légaré et al., 2010; Légaré and Witteman, 2013; Sepucha et al., 2016) (Fig. 17.2). Gravel et al. (2006) also acknowledge that SDM relies on provider motivation and the experience of positive outcomes of SDM experienced by both the clinicians and patients involved. Although patients and healthcare team members often speak different languages, health literacy and the healthcare team's ability to provide health information in a manner that supports the patient's capacity to make an informed shared decision are vital (Edwards et al., 2009).

FIG. 17.2 Components of shared decision making.

SDM is not necessarily a natural process for the healthcare team. Légaré and Witteman (2013) identify three elements that are critical for SDM, including recognition that a decision needs to occur, knowledge of evidence-based practice and ensuring that the patients’ values are part of the decision-making process. Although SDM has been particularly addressed as a role for physicians, all members of the healthcare team can assist and be involved in SDM. Makoul and Clayman (2006) provide an integrative model that identifies essential elements of SDM. These elements include the following:

■ The problem is defined by patients and 413

providers. ■ Options are presented with supportive physician knowledge and recommendations. ■ Benefits and risks are discussed. ■ Patient values and preferences are included. ■ The ability for the patient to follow through with the plan is discussed. ■ There is an opportunity for any reclarification. ■ The decision is made or deferred. ■ Follow-up is organized.

Barriers to Shared Decision Making Overcoming barriers to SDM can facilitate its adoption and use across healthcare settings. Historically, healthcare decisions were made utilizing a paternalistic approach, and this continues across many healthcare settings today. As with any change in healthcare delivery, barriers exist in the implementation of SDM. When it comes to the healthcare team, barriers can occur with or between individual practitioners and could include differences in healthcare knowledge, attitudes or beliefs that are not supportive of SDM and lack of agreement among team members when making a decision (Légaré et al., 2008, 2013). Similar to the barriers seen in implementing interprofessional care, SDM faces challenges when healthcare team members do not dedicate time to discuss the processes of SDM. Lack of investment of time in identifying the processes of SDM leads to discrepancies in how decisions are made, which may cause conflict among the team members and the patient. Healthcare team members must commit to SDM and not let issues like individual practitioners’ lack of motivation or self-confidence interfere with SDM (Légaré et al., 2008). SDM may also be a challenge when patients are not interested in being part of the decision process. Depending on differences in culture and health beliefs, some patients may find the process of being asked to engage in SDM uncomfortable and countercultural. These beliefs can act as barriers to the successful implementation of SDM. Beyond providers and patients, systemic barriers exist for

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SDM, including time constraints, lack of resources to support SDM, reimbursement concerns and lack of organizational support. Some barriers may not actually exist but may be perceived to occur, such as lack of support for SDM by the healthcare system or healthcare team; such support and relevant infrastructure for implementation of SDM are necessary at team and organizational levels (Légaré et al., 2008).

Reflection Point 1 How do these barriers for SDM apply to your practice?

Shared Decision Making in Practice SDM in practice environments calls upon healthcare teams to take on a healing- and wellness-oriented approach rather than a scientific approach based on cure and pathology. Such an approach recognizes not only scientific evidence but also human perspectives and aspirations in healthcare decisions. The first step in implementing SDM is ensuring that all healthcare team members are educated and understand how to engage in SDM. Team members must address their own professional socialization issues and enculturation, including attitudes of paternalism and power that often influence the patient, family and team. Next, healthcare team members need to become comfortable with uncertainty, which will help them assist patients to recognize that much of health care includes varied levels of uncertainty that can be uncomfortable for all involved. Yet SDM offers an avenue for addressing uncertainly and further dialogue by all stakeholders, including patients, families and members of the healthcare team. Ultimately, addressing uncertainty and encouraging further dialogue in an open and honest forum can facilitate positive healthcare decisions (Braddock 2012).

Cultural Influences: Individual and Organizational on Shared Decision Making Individual cultural beliefs and values have an influence on SDM.

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Healthcare providers’ norms, language and practices are formed and framed within a cultural perspective that is unique to each individual and profession (Pecukonis et al., 2008). Both patients and healthcare professionals hold cultural beliefs and stereotypes about each other. Recognizing how beliefs and perceptions are formed about other people, professions and the roles that (healthcare) professionals play are important all of these factors directly affect the development and implementation of SDM practices. Realizing the opportunities and challenges created by professionalism and intercultural interactions with the patient is important and helps identify opportunities and barriers to communication and collaboration with patients. This, in turn, helps ensure that SDM promotes optimal health outcomes (Légaré et al., 2008). Barriers between patients and providers can lead to medical errors, poor patient outcomes, decreased patient satisfaction and health disparities (Nelson, 2002). Organizations are composed of individuals with beliefs, values and practices that are unique to each person but which unite and represent the overall organizational culture. Leadership, operational procedures and processes, care practices and employee behaviours are influenced by the organizational culture. Shared decision-making processes are congruent with organizational cultures that demonstrate strong, mutually respectful relationships between the patient, care providers and interprofessional healthcare team. An organization that adopts and supports a shared relationship model (i.e., relational coordination, relational coproduction and relational leadership) contributes to operational success and positive outcomes for the organization (Gittell et al., 2012; Moreau et al., 2012). Adopting SDM principles can help interprofessional teams by supporting a shared mental model that has been identified as a strategy for success among interprofessional teams (Ginsburg and Tregunno, 2005). Fortunately, many of the SDM practice environment and organizational culture issues can be addressed simultaneously with interprofessional collaborative practice development.

Case Study 17.1

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Shared Decision Making Tom, a 45-year-old construction worker, has an appointment at a recently opened ambulatory care clinic in his neighbourhood. When making his appointment, Tom reported he experienced a fall a couple days ago hurting his wrist and ankle. During the phone call for the appointment, the front desk staff asked Tom to begin thinking about options for his care and his priorities. The front desk scheduler explains to Tom that the clinic uses a healthcare team, and he may be seen by multiple professionals to address his issues, and patients are a valued member of this team. She indicates Tom will have an active role in deciding his care. After arriving for the appointment, the front desk receptionist reiterates to Tom that he will see a team and that at the clinic patients are encouraged to voice their desires for their care. Once Tom is checked in, the medical assistant brings him back to an examination room to get a brief history and also learns that he recently lost his job as a construction worker. The medical assistant encourages Tom to share this with the provider and also documents it in the electronic health record. During the patient interview, the medical assistant observes and notes that some cuts Tom received from the fall do not look well cleaned. The medical assistant mentions this to Tom, and Tom asks what he could do to keep them clean. At this request, the medical assistant cleans the cuts and educates Tom how to properly keep the wounds clean. Before departing the examination room, the medical assistant encourages Tom to ask questions during his visit and share how he wants his care delivered. The medical assistant enters the ambulatory care pod, where clinicians can speak openly about patients, and shares information from the brief patient history. As a result of previous physician visits, Tom believes that he will just be getting some medication and sent on his way. He does not realize that behind the doors of his room, there is a large team of medical professionals collaborating to meet all of his needs. Tom is also viewed as a valued member of this team who will be asked to help make decisions regarding his care. The healthcare team, including Tom, is committed to engaging patients in their health care and value-shared decision making as part of patient care. The team is composed of a medical assistant, medical resident, occupational therapist, pharmacist, physical therapist,

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psychologist, public health nurse, radiological technician and social worker. The team holds the value that all members of the team, including the patient, can speak up and advocate for the patient. Patients are informed about the opportunity to be engaged in their care and encouraged to engage in SDM as part of the team. The psychologist acts as the team coach supporting the team and its members, ensuring that the team works effectively. He or she ensures that the patient is included and is a facilitator for SDM among the team and the patient. The team engages in ‘huddles’ twice a day, where team members identify clinic issues for each session followed by a previsit planning session, where the healthcare team reviews the patient caseload for the session. When a patient's case is considered complex, any team member can identify the individual for case review at the weekly interprofessional care planning meeting. The medical resident enters the room after being briefed by the medical assistant. She reviews with Tom the concerns the medical assistant reported. Upon this review, the medical resident informs Tom that she wants him involved with deciding the next steps in his care. Tom tells her his priority is his wrist, but he is very concerned that if it is broken he will not have insurance for followup. The medical resident acknowledges this fear and tells Tom she would recommend a radiograph to determine whether it is broken. She would also like him to visit with the social worker to discuss options for job opportunities and insurance coverage. She would recommend a prescription of an antibiotic for his cuts because of risk for infection. Tom reports he would like to first determine whether his wrist is broken with a radiograph. He feels this is a good first step. Upon exiting the examination room, the medical resident with physician supervision identifies that she and Tom identified the following priorities: ■ radiograph of wrist to determine potential fracture, ■ prescription for antibiotic to address potential infection in his cuts and ■ referral to social work to address recent job loss. The resident knows he has access to many resources on the

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healthcare team but also recognizes that Tom is feeling very overwhelmed from the fall and his job loss. The medical resident proceeds to review all the options with the patient including inviting him to attend the interprofessional team meeting later that week. Tom gets a little teary eyed, admitting to the resident that with his job loss, he will soon lose health insurance coverage. He is anxious about accessing other services because of cost. The resident recommends that because of the acuteness of his wrist injury, a radiograph is highly recommended at the appointment. He encourages Tom to take a moment to consider his options and leaves the examination room. Tom decides that he would like the radiograph and to visit with the social worker. Because of transportation issues, he does not feel he can come back to the clinic for the interprofessional team meeting but is willing to have the team discuss options and have the social worker follow up with him. When the healthcare team meets to discuss Tom's case, the medical resident reports concern for Tom, including the possibility of developing depression because of his recent job loss. The team decides that the social worker will contact Tom to discuss his options, especially related to his wrist fracture confirmed via the radiograph. Because of the collaboration of the interprofessional team and efforts to engage Tom in SDM, the healthcare team is able to work with him to identify his prioritized needs that include finding a new job, which is identified as a priority by both Tom and the healthcare team.

Reflection Point 2 What attributes of SDM and key elements of organizational culture contributed to a collaborative team approach in this case?

Interprofessional Collaborative Practice and Shared Decision Making When the Core Competencies for Interprofessional Collaborative Practice (IPCP) were released in 2011, these competencies provided a foundation for a larger discussion about interprofessional

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education and practice (Interprofessional Education Collaborative, 2011, 2016). Healthcare professions exhibit many differences, including their professional cultures, but they have one thing in common: their caring for the patient and family. Despite their differences, all healthcare professionals identify with ‘a sense of shared purpose to support the common good in healthcare, and reflect a shared commitment to creating safer, more efficient and more effective systems of care’ (Interprofessional Education Collaborative, 2011, p. 17). The intent of interprofessional collaboration is that clinicians work ‘deliberatively’ together with the patient and family to provide optimal health care. Based on the principles and values of IPCP, healthcare professionals must learn to work in teams to collaborate ‘with others through shared problem-solving and SDM, especially in circumstances of uncertainty’ (Interprofessional Education Collaborative, 2011, p. 24). Despite extensive literature supporting SDM as a valuable approach for the patient and single physician, emerging models for SDM with the interprofessional care team are increasingly supported as a means of helping the team engage in collaborative patient-centred care planning (Légaré et al., 2010).

Implementation of the Interprofessional Shared Decision-Making (IP-SDM) Model Légaré et al. (2010, 2011a, 2013) implemented and tested a IP-SDM model. They found the model useful and easy to understand for team members during the implementation phase of SDM. The authors report that the model served as an excellent guide, enhanced the team's understanding of the conceptual foundation of the SDM process and enhanced collaboration within the interprofessional team. Having a team member enact the role of a decisional coach has been found to be a successful strategy during the implementation process of IP-SDM (Shunk et al., 2014). Decision coaches can be any one of multiple team members who helps the patient, family and healthcare team members reach a decision based on the principles of SDM. Coaches help the team engage in effective SDM by overseeing the process and providing feedback to team members. Through this process, team members develop in their abilities with SDM. Decision coaches can be members of the healthcare team who agree to take on this additional role to support

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the interprofessional healthcare team. The IP-SDM model with six process steps is outlined in Table 17.1. TABLE 17.1

Interprofessional Shared Decision-Making Model Steps Description 1. Patient presents ‘professionals share their knowledge and understanding (at the healthcare of the options with the patient while recognizing centre), and a equipoise* and the need for a decision’ (Légaré et al., decision needs to 2011b, p. 21). be made *a balance of forces or interests 2. Exchange of ‘The health professional(s) and the patient share information information about the potential benefits and harms of the options, using educational material, patient decision aids, and other evidence-based resources’ (Légaré et al., 2011b, p. 22). 3. Value Clarifying values by all involved in the decision-making clarification process. 4. Feasibility of The healthcare team has a good understanding of options options available to the patient. 5. Decision Team members agree upon a decision. 6. Support patient Healthcare team members support the patient revisiting the decision as needed.

Although there are limitations identified in using the IP-SDM model, Yu et al. (2014) identified that these limitations can be resolved by a deliberative interprofessional team that is engaged in respectful communication. The challenges with implementing interprofessional collaborative practice have been well documented and are no different from the support needed for SDM in the interprofessional team. Barriers to SDM for the interprofessional team include issues with knowledge of IP-SDM and patient-centred care among team members, team performance norms, individual team members’ attitudes and perceptions towards IP-SDM, external factors like reimbursement and organizational support by leadership (Chong et al., 2013). Clinicians may have differing opinions of how much patients should be involved in SDM. Yet IPSDM can be supported and facilitated through training of team members, establishing team commitments among team members and organizational support. The barriers and supports for both SDM and interprofessional care align. Overall, in order for SDM to be successful in the interprofessional care model, the healthcare

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team has to work through the basic principles of team development to ensure that power dynamics are conducive to SDM and essentially work towards becoming a high-performing, collaborative team (Légaré et al., 2010). Furthermore, there has to be support from the healthcare environment and the healthcare team in order for the SDM to be successful (Légaré et al., 2011a).

Important Influences for Successful Implementation and Sustainability of Shared Decision Making Shared values, good communication, trust and supportive organizational culture are essential influences important for SDM to occur (Müller et al., 2016). SDM relies upon the healthcare team to ensure the patient perspective is valued. The development of this value occurs through building trust and relationships with patients through active listening and engaging in empathy. The process of SDM, which involves transparency and patient empowerment, can act as a venue to naturally facilitate trust building among the patient, family and healthcare team (Braddock, 2012). Epstein and Street called upon healthcare providers to promote SDM by developing a shared mind. A shared mind is characterized as a situation in which ‘new ideas and perspectives emerge through the sharing of thoughts, feelings, perceptions, meanings and intentions among two or more people’ (Epstein and Street, 2011, p. 455). Interprofessional teams need to see themselves working collaboratively with the patient as a ‘shared mind’ (Epstein and Street, 2011, p. 455).

Electronic Health Records for Successful Implementation and Sustainability of Shared Decision Making Electronic health records (EHRs) play an important part in the success of implementing and sustaining SDM. Essentially, EHRs can offer institutional support to the clinicians and the healthcare system to support SDM. Integrating processes to document SDM into electronic health records has been identified as a strategy to accelerate the adoption of SDM into health care (Oshima Lee and Emanuel, 2013). Ideally, the EHR system can build a tailored SDM program based on the patient's personal and clinical characteristics

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(Légaré et al., 2013). For clinicians new to SDM, the EHR can include decisional aids and reminders to clinicians to engage in SDM with patients. Technology, such as EHRs, can help embed the tools and reminders needed to help SDM become a part of the healthcare team's daily processes. In a similar way to how patients use technology to manage and track health, EHRs can provide support to the healthcare team enacting SDM by providing reminders, decisional aids and tracking systems. Allowing patient access to these portions of the EHR also helps promote patient empowerment and SDM (Légaré et al., 2013). Electronic health records have been identified extensively in the literature as a tool to support the implementation of SDM (Archer et al., 2011; Tinetti et al., 2012). Although it is clear that EHRs can be a tool to implement SDM, clinicians must make a concerted effort to design processes to use the tools and document SDM in the EHR. In other words, simply building reminders and decisional aids into EHRs has not been proven to guarantee use. The opportunity exists to have EHRs support SDM but is commonly still underutilized (Davis et al., 2017).

Decisional Aids for Successful Implementation and Sustainability of Shared Decision Making Decisional aids have been instrumental in promoting SDM in encounters between interprofessional teams and the patient. Decisional aids provide patients with information on disease, describe complex health scenarios and treatment options for patients to improve the quality of the decision-making process (Sepucha et al., 2013) and reduce decisional conflict or uncertainty (Ruland and Bakken, 2002). The International Patient Decision Aids Standards Collaboration's (IPDAS, n.d.) focus is to increase the quality of decisional aids, and they developed a criterion-based checklist involving 12 domains to evaluate the content and effective use of decision aids (McDonald et al., 2011). To date, there are over 1,000 decisional aids that have been developed, used and studied within the healthcare system. The feasibility of continuing to produce these for every disease entity and treatment option has been brought into question. A universal decision support aid system has been proposed that allows clinicians and patients/families to input information specific to their situation and

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cultural context. This may be a promising solution that continues to be investigated (Cox et al., 2014).

Outcomes of Shared Decision Making SDM effectiveness with patient, provider, interdisciplinary team and organizational outcomes continues to be a focus of study. Establishing a consistent conceptual definition with methodologically sound measures must be a priority for continued research. Most outcome studies have focussed on disease-specific patient outcomes with variant results. See Table 17.2 for a range of outcomes. TABLE 17.2

Outcomes of Shared Decision Making PatientFocussed Outcomes ■ Satisfaction with care and SDM processes ■ Adherence to the decision or mutual agreement ■ Levels of decisional conflict or uncertainty ■ Clinical outcomes specific to the treatment plan ■ Decisional conflict ■ Improved quality of life

Provider-Focussed Outcomes

Interdisciplinary Team Outcomes

Organizational Outcomes

■ Knowledge of the SDM ■ Focussed process primarily on ■ Satisfaction with SDM other individual practice team members ■ Changes in relationship of patient/provider based on the SDM practice/processes

■ Teamwork in practice ■ Costs associated with testing ■ Diagnostic procedures ■ Length of stay

Based on Hauser et al., 2015; Körner et al., 2013; Sepucha et al., 2016

The available measurement tools for both processes and outcomes of SDM are extensive (Table 17.3) and represent the providers’ view, patient view and both. Bouniols et al. (2016)

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provide a systematic review of tools and utilize a unique summary evaluating the tools based on the inclusion of essential elements of SDM identified in Makoul and Clayman's (2006) integration model of SDM. Bouniols et al. (2016) provide one of the most up-to-date reviews of measurement tools for SDM. TABLE 17.3

Measurement Tools for Shared Decision Making SDMQ (Scholl et al., 2012) Define/explain problem X Present options X Discuss pros/cons X Values/preferences X Patient ability/self-efficacy 0 Knowledge/recommendations 0 Check/verify understanding X Make or defer decision X Arrange follow-up X

Dyadic Measure (Légaré et al., 2012)

IDM (Leader et al., 2012) X X X X 0 0 X 0 0

X X X X X X X 0 0

Mappin SDM (Kasper et al., 2012) X X X X 0 X X X X

X 0 0 X 0 0 X 0 0

Chapter Summary In this chapter, we have outlined:

■ the attributes and barriers of SDM, ■ how interprofessional teams approach SDM in practice with consideration of the key, cultural and organizational factors that influence successful implementation of SDM, in particular shared values, good communication and trust, ■ other factors important for implementation and sustainability, including electronic health record and decisional aids, and ■ a description of models, key outcomes and 425

measurement of SDM. Reflection Point 3 Why is SDM a challenge in comparison to traditional approaches to clinical reasoning? What teaching and learning strategies might be most effective to help develop SDM commitment and abilities? How do you think EHR might facilitate SDM?

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2013;27:223–230. Cox C, White D, Abernethy A. A universal decision support system: addressing the decision-making needs of patients, families, and clinicians in the setting of critical illness. Am. J. Resp. Crit. Care Med.2014;190:366–373. Davis S, Roudsari A, Raworth R, et al. Shared decision-making using personal health record technology: a scoping review at the crossroads. J. Am. Med. Inform. Assoc.2017 [Available from:] https://doi.org/10.1093/jamia/ocw172. Edwards M, Davies M, Edwards A. What are the external influences on information exchange and shared decision-making in healthcare consultations: a meta-synthesis of the literature. Patient Educ. Couns.2009;75:37–52. Epstein R, Street R. Shared mind: communication, decision making, and autonomy in serious illness. Ann. Fam. Med.2011;9:454–461. Ginsburg L, Tregunno D. New approaches to interprofessional education and collaborative practice: lessons from the organizational change literature. J. Interprof. Care. 2005;19(Suppl. 1):177– 187. Gittell J, Godfrey M, Thistlethwaite J. Interprofessional collaborative practice and relational coordination: improving healthcare through relationships. J. Interprof. Care. 2012;27:210–213. Gravel K, Légaré F, Graham I. Barriers and facilitators to implementing shared decisionmaking in clinical practice: a systematic review of health professions perceptions. Implement. Sci.2006;9:1–16. Hauser K, Koerfer A, Christian K, et al. Outcome-

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relevant effects of shared decision making: a systematic review. Dtsch. Arztebl. Int.2015;112:665– 671. International Patient Decision Aids Standards Collaboration (IPDAS). [n.d; Viewed 7 April 2017; Available from:] http://ipdas.ohri.ca. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Interprofessional Education Collaborative: Washington, DC; 2011. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Interprofessional Education Collaborative: Washington, DC; 2016. Kasper J, Hoffmann F, Heesen C, et al. MAPPIN'SDM: the multifocal approach to sharing in shared decision making. PLoS ONE. 2012;7:123. Körner M, Ehrhardt H, Steger A. Designing an interprofessional training program for shared decision making. J. Interprof. Care. 2013;27:146–154. Leader A, Daskalakis C, Braddock CH, et al. Measuring informed decision making about prostate cancer screening in primary care. Society for Medical Decision Making. 2012;32:327–336. Légaré F, Witteman H. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff. (Millwood). 2013;32:276–284. Légaré F, Ratté S, Gravel K, et al. Barriers and facilitators to implementing shared decisionmaking in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ. Couns.2008;73:526–535. Légaré F, Ratté S, Stacey D, et al. Interventions for improving the adoption of shared decision making

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by healthcare professionals. Cochrane Database Syst. Rev.2010;(5) [CD006732]. Légaré F, Stacey D, Brière N, et al. A conceptual framework for interprofessional shared decision making in home care: protocol for a feasibility study. BMC Health Serv. Res.2011;11:23. Légaré F, Stacey D, Brière N, et al. Healthcare providers’ intentions to engage in an interprofessional approach to shared decisionmaking in home care programs: a mixed methods study. J. Interprof. Care. 2013;27:214–222. Légaré F, Stacey D, Pouliot S, et al. Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model. J. Interprof. Care. 2011;25:18–25. Légaré F, Turcotte S, Robitaille H, et al. Some but not all dyadic measures in shared decision making research have satisfactory psychometric properties. J. Clin. Epidemiol.2012;65:1310–1320. Makoul G, Clayman M. An integrative model of shared decision making in medical encounters. Patient Educ. Couns.2006;60:301–312. McDonald H, Charles C, Gafni A. Assessing the conceptual clarity and evidence base of quality criteria/standards developed for evaluating decision aids. Health Expect.2011;17:232–243. Moreau A, Carol L, Dedianne M, et al. What perceptions do patients have of decision making (DM)? Toward an integrative patient-centered care model: a qualitative study using focus-group interviews. Patient Educ. Couns.2012;87:206–211. Müller E, Hahlweg P, Scholl I. What do stakeholders need to implement shared decision making in routine cancer care? A qualitative needs assessment. Acta Oncol. (Madr). 2016;55:1484–1491.

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Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J. Natl Med. Assoc.2002;94:666–668. Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N. Engl. J. Med.2013;368:6–8. Pecukonis E, Doyle O, Bliss D. Reducing barriers to interprofessional training: promoting interprofessional cultural competence. J. Interprof. Care. 2008;22:417–428. Ruland C, Bakken S. Developing, implementing, and evaluating decision support systems for shared decision making in patient care: a conceptual model and case illustration. J. Biomed. Informat.2002;35:313–321. Scholl I, Kriston L, Dirmaier J, et al. Development and psychometric properties of the shared decision making questionnaire-physician version (SDM-QDoc). Patient Educ. Couns.2012;88:284–290. Sepucha K, Borkhoff C, Lally J, et al. Establishing the effectiveness of patient decision aids: key constructs and measurement instruments. BMC Med. Inform. Decis. Mak.2013;13(Suppl. 2):S12. Sepucha K, Breslin M, Graffeo C, et al. State of the science: tools and measurement for shared decision making. Acad. Emerg. Med.2016;23:1325–1331. Shunk R, Dulay M, Chou C, et al. Huddle-coaching. Acad. Med.2014;89:244–250. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition— multimorbidity. JAMA. 2012;307:2493–2494. Yu C, Stacey D, Sale J, et al. Designing and evaluating an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes in clinical care: systematic decision aid

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18

Using Decision Aids to Involve Clients in Clinical Decision Making Lyndal Trevena, Kirsten Mccaffery

CHAPTER AIMS The aims of this chapter are to: ■ introduce the principles of shared decision making and the potential role of patient decision aids, ■ define the types of clinical decisions that are best suited to the use of patient decision aids, ■ outline the evidence for the effectiveness of patient decision aids on involving patients in clinical decisions, ■ outline the International Patient Decisions Aids Standards (IPDAS) and how they can be used to assess the quality of patient decision aids, ■ introduce emerging evidence on team-based decision making in health care and

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■ introduce emerging evidence on involvement of patients with lower health literacy.

KEY WORDS Decision aids Patient involvement The evidence-base Quality standards

ABBREVIATIONS IPDAS International Patient Decision Aids Standards SDM Shared decision making RCT Randomized controlled trial

Introduction Shared decision making (SDM) is a process by which a healthcare decision is made collaboratively among a patient, healthcare professionals and others. It has also been described as ‘collaborative deliberation’ (Elwyn et al., 2014) with one of the key components of this process being to ensure that both knowledge and power are shared between the healthcare professional and the patient (JosephWilliams et al., 2014). This is an important and effective strategy for involving clients in decisions about their health care. Increasingly, client involvement is being included in policies such as the US Affordable Care Act and the UK's ‘No decision about me without me’ report (Department of Health, 2011). Similarly, Canada, France, Germany, Netherlands and Australia all have policies and patient charters that include greater client involvement in healthcare decisions. There are many different strategies and tools that can be used to facilitate this process (Hoffmann et al., 2014), but arguably the most studied of these (and the focus of this

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chapter) are patient decision aids.

What Is A Patient Decision Aid? The International Patient Decision Aids Standards (IPDAS) Collaboration (Trevena et al., 2013) defines decision aids as “evidence-based tools designed to help patients to participate in making specific and deliberated choices among healthcare options” (Trevena et al., 2013, n.p.). They are intended to supplement (rather than replace) conversations with healthcare professionals, and they generally will: 1. ‘Explicitly state the decision that needs to be considered; 2. Provide evidence-based information about a health condition, the options, associated benefits, harms, probabilities and scientific uncertainties; 3. Help patients to recognize the values-sensitive nature of the decision and to clarify, either implicitly or explicitly, the value they place on the benefits and harms. (To accomplish this, patient decision aids may describe the options in enough detail that clients can imagine what it is like to experience the physical, emotional and social effects and/or guide clients to consider which benefits and harms are most important to them)’ (Stacey et al., 2014, n.p.). Patient decision aids are different to patient education materials because they aim to personalize the decision for the individual patient and facilitate patient involvement rather than simply provide explanatory information about diseases and their management. Decision aids are designed to provide a balanced and neutral presentation of the options in healthcare decisions. Such aids may be concise or detailed; they can be provided in hard copy or online; they may include videos and/or graphics; and they can be used within or outside the health consultation. Many of them are based on theoretical frameworks (Fig. 18.1).

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FIG. 18.1 Excerpt from MMR (Measles, Mumps and

Rubella) Decision Aid. (From Leask, J., Wallace, C., Trevena, L., Jackson, C., Shouri, S., 2009. MMR decision aid, http://www.ncirs.edu.au/consumer-resources/mmr-decision-aid/, with permission.)

When Should You Consider Using a 435

Decision Aid? Decision aids are one way that patients can be involved in their healthcare decisions. It is not practical (or even necessary) to use a patient decision aid in every health decision, but we know that patients tend to want a more active role in certain decision types. These include: 1. decisions relating to preventive health care, 2. situations with potential negative future consequences, e.g., chronic diseases, 3. decisions where evidence is lacking or uncertain and 4. decisions involving potential side effects, e.g., immunization, antihypertensive therapy (Müller-Engelmann et al., 2013). For some decisions, there is clear evidence that a test or treatment should be recommended. Its benefits clearly outweigh any harms, and it may be lifesaving. The healthcare worker has an obligation to recommend such treatment and to ensure that the patient's consent is valid. In other words, an evidence-based recommendation is made and the patient is made aware of the likelihood of benefits and harms. Even with this ‘consider a recommendation’ approach (Entwistle et al., 2008), some patients will remain uncertain and want more detailed information (Waller et al., 2012). A decision aid may be a very well-received option in such cases (see Case Studies 18.1 and 18.2).

Case Study 18.1

Bowel Cancer Screening Many countries around the world have national screening programs for bowel cancer. There is good evidence that biennial faecal occult blood testing (FOBT) every 2 years has a modest effect on reducing the incidence and mortality of bowel cancer, but there are risks associated with colonoscopies arising from positive results – true and false (Hewitson et al., 2007). Governments have therefore invested in FOBT screening programs and offer the test to people in the target age range. A UK study showed that the

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majority of the British public (84%) preferred an expert recommendation about bowel cancer screening, but they also wanted to be informed about the benefits and risks. Conversely, around 16% people prefer to weigh up the benefits and harms for themselves (Waller et al., 2012).

Case Study 18.2

Measles Vaccination The World Health Organization estimates that around 17 million lives have been saved since 2000 as a result of childhood vaccination. Although there are rare serious consequences of vaccination, the benefits of vaccination substantially outweigh the harms. Most parents are accepting of the recommendation to vaccinate their children against measles, but some have concerns and are not accepting. In these cases, patient decision aids can be a useful way to involve parents in decisions through clarifying what's important to them and providing balanced information about the consequences of vaccinating or not vaccinating. In fact, a randomized controlled trial (RCT) of a patient decision aid with parents who were vaccine-hesitant showed that those receiving the decision aid were more likely to vaccinate their children than those who received a government-developed leaflet (Shourie et al., 2013). The web-based tool was also likely to be cost effective (Tubeuf et al., 2014). There are also many decisions in which we should recommend against a test or treatment because it may cause significant harm with little or no benefit. The healthcare worker in this case has a duty of care to explain this for patient safety. An example of this type of decision is not ordering x-rays for people with acute nonspecific low back pain (provided they do not have any ‘red flag’ symptoms or signs). Imaging provides no benefit to these patients but exposes them to unnecessary radiation and financial costs (Maher et al., 2016). Patient decision aids are most commonly used when there is equipoise (a trade-off between benefits and harms) and where patient preferences have an important role to play. There may be a

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number of reasonable options to choose from, and the individual patient may place importance on particular factors such as side effects, efficacy and financial costs (Box 18.1).

Box 18.1

Examples of Clinical Decisions Potentially Suited for Decision Aids Choosing treatment for: ■ early-stage prostate cancer (surgery vs radiotherapy vs active surveillance), ■ knee osteoarthritis (pharmacological vs nonpharmacological), ■ quitting smoking (pharmacological vs nonpharmacological) and ■ mild-moderate depression (antidepressant vs psychological vs both). For example, when smokers want to quit, they have the choice of a number of options for smoking cessation – ‘no treatment’, nicotine replacement patches/gum and prescription medications. Some smokers will prefer to quit with the assistance of nicotine replacement therapy, and others will choose ‘no treatment’ when provided with the evidence for benefits and harms of each option. A recent RCT of a smoking-cessation decision aid app showed a significant increase in continuous abstinence after 6 months compared with a traditional patient education app. Allowing patients to choose an option that aligns with their personal goals, values and circumstances in this way can result in better health outcomes (BinDhim et al., 2014; Müller-Engelmann et al., 2013).

How Do Decision Aids Work? The most recent update of the Cochrane systematic review of patient decision aids includes 105 RCTs and shows that they significantly increase patients’ knowledge and that patients are more likely to make a decision that is concordant with their

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personal values. Decision aids improve patients’ accuracy of risk perception, reduce decisional conflict and increase patient involvement. These findings appear to be similar regardless of whether the decision aid is used within or outside the healthcare consultation (Stacey et al., 2014). It is important to ensure that within the clinical reasoning process, decision points are identified and the need for a tool is assessed. It is also important to find the right tool for the situation. This involves being sure that the tool is relevant to your patient's context.

Reflection Point 1 Some questions to ask yourself are: Question: What type of patient is the decision aid designed for? Rationale: Applying evidence across different population groups needs caution. The rate of a particular outcome can change in certain patient subgroups (e.g., age, family history, ethnicity and social circumstances can all have an effect). Question: What health decision is the tool designed for? Rationale: It is important to ensure that the tool aligns with the decision facing your patient. Question: Are the options relevant to the patient's context? Rationale: Some treatments may not be available or affordable in particular contexts.

What Makes a ‘Good’ Decision Aid? The IPDAS Collaboration published a series of articles in 2013 detailing the evidence supporting their standards (Volk et al., 2013). As more patient decision aids are being developed, it is becoming increasingly difficult for healthcare workers and patients to be sure of the quality of these tools. The IPDAS series of manuscripts summarizes the evidence for decision aid developers and users when appraising the quality of tools (Box 18.2).

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Box 18.2

Some Factors Relevant to the Quality of Patient Decision Aids 1. What was the development process? 2. Are there any relevant conflicts of interest, and have they been disclosed? 3. Are all the options set out clearly? 4. Is the information evidence-based? 5. Is the information presented in a balanced way? 6. Are the quantitative outcomes of the options presented clearly? 7. Can patient values be clarified? 8. Is the decision aid accessible to people across the health literacy spectrum? Adapted from the IPDAS series of manuscripts in BioMedCentral (see Volk, R.J., Llewellyn-Thomas, H., Stacey, D., Elwyn, G., 2013. Ten years of the International Patient Decision Aid Standards Collaboration: evolution of the core dimensions for assessing the quality of patient decision aids. BMC Med. Inform. Decis. Mak. 13[suppl. 2], S1).

Unfortunately, many patient decision aids have been developed for research purposes and have not subsequently been made available to the public. In addition, many have been published and not updated with the latest evidence. A small audit of the Ottawa A to Z Inventory of Patient Decision Aids (Ottawa Hospital Research Institute, n.d.[a]) found that only one-half had provided references for the evidence used or the date they were last updated (Montori et al., 2013). It has been suggested that evidence-based systematic reviews should be updated every 2 to 5 years (Shojania et al., 2007). Thus, when looking for a decision aid, use it with caution if it is more than 5 years old and has not been updated. It may also be necessary to supplement a decision aid with locally relevant information about costs, resources and accessibility for particular treatment options. These issues can be important to decision making with clients but are less frequently included in published decision aids (McCurtin and Clifford, 2015). Similarly, the role of

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patient stories and experiences within decision aids has been controversial, with insufficient evidence to support their inclusion routinely (Bekker et al., 2013). Disclosure of conflicts of interest is another important quality issue for patient decision aids. A recent analysis of disclosure policies among 25 organizations that develop patient decision aids showed that only 6 of the 12 who responded had any written policy of disclosure (Elwyn et al., 2016). Similar problems with lack of disclosure have been highlighted for clinical practice guidelines (Norris et al., 2011). It is important to consider the developers of a decision aid and whether there could be potential conflicts of interest. It has been suggested that patient decision aid certification is a mechanism for addressing some of these quality issues. The IPDAS Collaboration has developed a set of minimum standards for patient decision aid certification to address this need, identifying 6 items that confirm that a tool ‘qualifies’ as a decision aid; 10 items for use in ‘certification’; and 28 ‘quality’ criteria that will strengthen a decision aid but whose omission does not create a high risk for harmful bias (Joseph-Williams and Newcombe et al., 2014). An analysis of 30 decision aids from the Cochrane review were scored against these items and found that most met the qualifying criteria but only three met the proposed certification threshold (Durand et al., 2015). Most of these omissions were from a lack of update policy and disclosure of funding sources. The Washington Health Care Authority (n.d.) has implemented a certification process from 2016 that calls for submission four times per year, sends submissions for independent review, an opportunity for improvement after review and a requirement for recertification every 2 years.

Reflection Point 2 Consider the following issues in choosing a patient decision aid: • Who developed the decision aid, and have potential conflicts of interest been disclosed? • When was the decision aid last updated?

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• Using the IPDAS checklist, how does the decision aid score?

Where Can You Find Patient Decision Aids? Although you can search on the Internet for patient decision aids, this often results in poor-quality resources and a maze of different alternatives that are hard to make sense of. Increasingly, reputable decision aid developers and groups worldwide are publishing their tools on the Internet. Box 18.3 provides a short list of some to consider.

Box 18.3

Examples of Patient Decision Aid Developer Websites Agency for Healthcare Research and Quality ■ http://www.effectivehealthcare.ahrq.gov/index.cfm/tools-andresources/patient-decision-aids/ ■ Cincinnati Children's Hospital Anderson Center Decision Aids ■ https://www.cincinnatichildrens.org/service/j/andersoncenter/evidence-based-care/decision-aids

Mayo Clinic Decision Aids ■ http://shareddecisions.mayoclinic.org/decision-aidinformation/decision-aids-for-chronic-disease/ ■ Med-Decs ■ http://www.med-decs.org

The Option Grids Decision Aids ■ http://optiongrid.org/option-grids/current-grids ■ Ottawa Health Research Institute Inventory A–Z

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■ https://decisionaid.ohri.ca/index.html ■ Université Laval Decision Boxes ■ http://www.decisionbox.ulaval.ca/index.php?id=810&L=2 A major equity issue at present is the restriction of access to patient decision aids. Some developers require membership of a particular health insurance agency. Some have restricted access to country-specific IP addresses, and others require payment to access.

What Is the Best Way to Involve Clients in Using Decision Aids? There does not appear to be any difference in the effect of patient decision aids whether they are used within or outside the healthcare consultation (Stacey et al., 2014). However, we do know that healthcare professional endorsement of decision aids has a positive effect on patient involvement (Légaré et al., 2014). It is also important to clarify how much involvement patients want in each health decision and to clearly separate ‘deliberation’ from ‘determination’ (Politi et al., 2013). Earlier in this chapter, we introduced the term ‘collaborative deliberation’, which involves exchanging knowledge, eliciting what is important to the patient, communicating about options, engaging patients in discussion and finding out what role they would like to play in the final decision. We also highlighted that many patients would prefer a recommendation but also want to know their options and their benefits and harms. More informed patients are also more likely to want involvement in decisions, and most patients (regardless of demographic characteristics) want to be offered choices about their care and asked about their preferences (Politi et al., 2013). Having done this, some will defer the actual decision (i.e., ‘determination’) to the healthcare professional or others. In other words, the preference for involvement needs to be informed by the deliberative process (Politi et al., 2013).

What Should I Do if I Cannot Find a 443

Relevant Decision Aid? If a specific decision aid cannot be found, you can either use a ‘generic’ decision support tool such as the one available from the Ottawa Hospital Research Institute (n.d.[b]). This guide is designed to help people with any personal or social decision; it is available in a version that might also include family members or others. It has been translated into French, Swedish, Dutch, Danish, Spanish German and Japanese. This website also has an online tutorial about how to use these generic tools in coaching someone through a decision. Another way to approach collaborative deliberation when a patient decision aid is not available is to use a simple question framework to encourage patients to be involved in decisions. Patients who are trained to ask these three questions are more likely to be actively involved in their healthcare decisions and more likely to have a discussion about the harms and benefits of treatment options (Shepherd et al., 2011) (Fig. 18.2).

FIG. 18.2 Three questions that patients can ask. (From Ask Share Know, n.d., The Ask Share Know project, www.askshareknow.com.au, with permission)

How Can the Health Team Play a Role? Despite the fact that there is an increasing emphasis on multidisciplinary teams in health care, there has been very little

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work on how SDM and patient decision aids might fit within this context. Two reviews of theories of interprofessional SDM highlighted the argument that very few make explicit the roles of team members in decision making and that family members are often subsumed into the patient role (Lewis et al., 2016; Stacey et al., 2010). For example, cancer multidisciplinary team meetings are variable in their involvement of patients, families and primary care professionals, and patients find the challenges of seeking second opinions to be particularly difficult (Hamilton et al., 2016). There has been very limited research into how nonmedical members of the healthcare team can include shared decision making as part of their daily clinical practice. Supporting patients’ involvement in their health care to the extent they would like should be part of all healthcare interactions. Relevant patient decision aids can be used and adapted in many encounters with allied healthcare professionals, although implementation to this extent is not yet routine. The implementation of SDM has been sporadic and often dependent on ‘champions’ at the institution. It is important to consider the workflow of the clinic and the patient journey as they navigate across the healthcare team. Involving teams in the design of SDM implementation plans is vital. In the future, we will hopefully see patient preferences and decisions shared across the healthcare team to ensure a more consistent and seamless experience (Lloyd et al., 2013).

Can Patient Decision Aids Be Used to Involve Family Members and Carers? Some patient decision aids have been developed to take into account that there may need to be a surrogate decision maker for the patient who is not able to give informed consent. This can include situations such as end-of-life care for unconscious patients, care decisions for patients with dementia or children who are not legally old enough to give informed consent. There are also situations such as pregnancy-related decisions in which any woman may wish to take into account the preferences of her partner. There are also some patients who simply prefer to involve their family or

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others in a healthcare decision, and healthcare professionals should take this into consideration whenever possible. Patients with lower levels of literacy appear to prefer greater involvement and consultation with family and others. A study of 73 men and women living in Australia with varying educational and functional health literacy showed that patients with lower education levels described how relatives and friends sought information on their behalf and played a key role in their decisions (Smith et al., 2009). However, all levels of literacy consistently saw the practitioner–patient relationship as being key to their involvement regardless of family roles. It is therefore important for healthcare professionals to balance and negotiate the preference for family involvement alongside the integrity of the relationship with the individual patient.

Reflection Point 3 Consider the following questions: • What other members of the healthcare team are involved in your patient's healthcare decision and its implementation? How do you ensure relevant communication with them? • To what extent does your patient want family members involved in this decision? How is that best done? • How would you be able to discern your patient's preferences for other team and family member involvement in decisions? Who will make the decisions, and how will the decisions be made?

Can Patients From Vulnerable Populations Benefit From Using Patient Decision Aids? At the beginning of this chapter, we outlined the principle that SDM is a process requiring an exchange of power within the clinician–patient communication (Joseph-Williams et al., 2014) and

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that the use of patient decision aids is an effective way to increase patient involvement resulting in better knowledge, understanding of risks and benefits and making decisions that are valuesconcordant. A subanalysis of the Cochrane systematic review of patient decision aids has shown that patients who had a lower baseline knowledge level had a greater effect from the decision aids than those with higher knowledge at baseline. In other words, there is the potential to reduce the socioeconomic knowledge gap through the use of such tools. Health literacy has been described as having ‘functional’, ‘critical’ and ‘communicative’ components (Nutbeam, 2000). The IPDAS criteria include the recommendation to consider literacy and numeracy in decision aid development. There is a growing body of evidence that patients with lower literacy do want involvement in healthcare decisions, but they are more likely to confer with family and friends and also to rely on the opinion of their healthcare worker in doing so (Smith et al., 2009). A review of patient decision aids for lower-literacy populations concluded that although there are few studies where research has been conducted, findings are encouraging (McCaffery et al., 2013). One trial of a patient decision aid for lower-literacy participants did show an increase in knowledge and informed choice compared with standard information, suggesting that they have potential for increasing patient involvement in decision making across all literacy levels (Smith et al., 2010).

Chapter Summary ■ Patient decision aids are useful tools to engage patients in healthcare decisions. ■ Healthcare professional endorsement of SDM is important for patient engagement in collaborative deliberation. ■ Most patients would like to know there is a choice, know what their options are and be asked 447

about their preferences. ■ Patients’ preferences for involvement in determination (i.e., making the choice) may mean that they defer this to others such as their healthcare professional. ■ Patient involvement in healthcare decisions can occur without a patient decision aid and is feasible and appropriate for patients from a range of demographic backgrounds. ■ Healthcare teams with the patient as a member are likely to be the future face of shared decision making. Reflection Point 4 Consider your daily work as a clinician. • Do you involve patients in decisions about their health care? Why or why not? • How do you currently do this? • What tools could you use to increase patient involvement in these decisions?

References Ask Share Know. The Ask Share Know project. [n.d.; Viewed 28 March 2017; Available from:] www.askshareknow.com.au. Bekker HL, Winterbottom AE, Butow P, et al. Do personal stories make patient decision aids more effective? A critical review of theory and evidence. BMC Med. Inform. Decis. Mak.2013;13:S9. BinDhim NF, McGeechan K, Trevena L. Assessing the effect of an interactive decision-aid smartphone

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smoking cessation application (app) on quit rates: a double-blind automated randomised control trial protocol. BMJ Open. 2014;4:e005371. Department of Health. Liberating the NHS: no decision about me, without me: further consultation on proposals to secure shared decision making. [Department of Health, London, UK] 2011. Durand MA, Witt J, Joseph-Williams N, et al. Minimum standards for the certification of patient decision support interventions: feasibility and application. Patient Educ. Couns.2015;98:462–468. Elwyn G, Dannenberg M, Blaine A, et al. Trustworthy patient decision aids: a qualitative analysis addressing the risk of competing interests. BMJ Open. 2016;6:e012562. Elwyn G, Lloyd A, May C, et al. Collaborative deliberation: a model for patient care. Patient Educ. Couns.2014;97:158–164. Entwistle VA, Carter SM, Trevena L, et al. Communicating about screening. BMJ. 2008;337:a1591. Hamilton DW, Heaven B, Thomson RG, et al. Multidisciplinary team decision-making in cancer and the absent patient: a qualitative study. BMJ Open. 2016;6:e012559. Hewitson P, Glasziou P, Irwig L, et al. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst. Rev.2007;(1) [CD001216]. Hoffmann TC, Légaré F, Simmons MB, et al. Shared decision making: what do clinicians need to know and why should they bother?. Med. J. Aust.2014;201:35–39. Joseph-Williams N, Elwyn G, Edwards A. Knowledge is not power for patients: a systematic

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review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Educ. Couns.2014;94:291–309. Joseph-Williams N, Newcombe R, Politi M, et al. Toward minimum standards for certifying patient decision aids: a modified Delphi Consensus Process. Med Decis Making. 2014;34:699–710. Leask J, Wallace C, Trevena L, et al. MMR decision aid. [Viewed 28 March 2017; Available from:] http://www.ncirs.edu.au/consumerresources/mmr-decision-aid/; 2009. Légaré F, Stacey D, Turcotte S, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst. Rev.2014;(9) [CD006732]. Lewis KB, Stacey D, Squires JE, et al. Shared decisionmaking models acknowledging an interprofessional approach: a theory analysis to inform nursing practice. Res. Theory Nurs. Pract.2016;30:26–43. Lloyd A, Joseph-Williams N, Edwards A, et al. Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC). Implement. Sci.2013;8:102. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2016;389:736–747. McCaffery KJ, Holmes-Rovner M, Smith SK, et al. Addressing health literacy in patient decision aids. BMC Med. Inform. Decis. Mak.2013;13(Suppl. 2):S10. McCurtin A, Clifford AM. What are the primary influences on treatment decisions? How does this reflect on evidence-based practice? Indications from the discipline of speech and language therapy. J. Eval. Clin. Pract.2015;21:1178–1189.

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Montori VM, LeBlanc A, Buchholz A, et al. Basing information on comprehensive, critically appraised, and up-to-date syntheses of the scientific evidence: a quality dimension of the International Patient Decision Aid Standards. BMC Med. Inform. Decis. Mak.2013;13(Suppl. 2):S5. Müller-Engelmann M, Donner-Banzhoff N, Keller H, et al. When decisions should be shared: a study of social norms in medical decision making using a factorial survey approach. Med Decis Making. 2013;33:37–47. Norris SL, Holmer HK, Ogden LA, et al. Conflict of interest in clinical practice guideline development: a systematic review. PLoS ONE. 2011;6:e25153. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot. Int.2000;15:259–267. Ottawa Hospital Research Institute. Ottawa A to Z inventory of patient decision aids. [n.d.(a); Viewed 28 March 2017; Available from:] https://decisionaid.ohri.ca/AZinvent.php. Ottawa Hospital Research Institute. Patient decision aids: Ottawa personal decision guides. [n.d.(b); Viewed 28 March 2017; Available from:] https://decisionaid.ohri.ca/decguide.html. Politi MC, Dizon DS, Frosch DL, et al. Importance of clarifying patients’ desired role in shared decision making to match their level of engagement with their preferences. BMJ. 2013;347:f7066. Shepherd HL, Barratt A, Trevena LJ, et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial. Patient Educ. Couns.2011;84:379–385.

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Shojania KG, Sampson M, Ansari MT, et al. How quickly do systematic reviews go out of date? A survival analysis. Ann. Intern. Med.2007;147:224– 233. Shourie S, Jackson C, Cheater FM, et al. A cluster randomised controlled trial of a web based decision aid to support parents decisions about their child's Measles Mumps and Rubella (MMR) vaccination. Vaccine. 2013;31:6003–6010. Smith SK, Dixon A, Trevena L, et al. Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Soc. Sci. Med.2009;69:1805–1812. Smith SK, Trevena L, Simpson JM, et al. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ. 2010;341:c5370. Stacey D, Légaré F, Col NF, et al. Decision aids for people who are facing health treatment or screening decisions. Cochrane Database Syst. Rev.2014;(1); 10.1002/14651858.CD001431.pub5 [CD001431]. Stacey D, Légaré F, Pouliot S, et al. Shared decision making models to inform an interprofessional perspective on decision making: a theory analysis. Patient Educ. Couns.2010;80:164–172. Trevena LJ, Zikmund-Fisher BJ, Edwards A, et al. Presenting quantitative information about decision outcomes: a risk communication primer for decision aid developers. BMC Med Inform Decis Mak. 2013;13(Suppl. 2):S7. Tubeuf S, Edlin R, Shourie S, et al. Cost effectiveness of a web-based decision aid for parents deciding about MMR vaccination: a three-arm cluster randomised controlled trial in primary care. Br. J.

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19

Clinical Decision Making, Social Justice and Client empowerment Debbie Horsfall, Diane Tasker, Joy Higgs

CHAPTER AIMS The aims of this chapter are to: ■ examine connections between clinical decision making (from person to system levels) in relation to social justice and empowerment, ■ reflect on the meaning of social justice and how it can be incorporated into health care and ■ promote reflection on practices in this arena.

KEY WORDS

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Social justice Empowerment

Introduction A child born today in Japan, for example, can expect to live to 82 years of age on average, whereas it is unlikely that a newborn infant in Zimbabwe will reach his or her 34th birthday. Extreme deprivation in health is still widespread. Resolving this predicament of major health improvement in the midst of deprivation is one of the greatest global challenges of the new millennium (Ruger 2004). The picture of a person's health cannot be complete without consideration and full acknowledgement of his or her place within the society in which he or she lives. Accordingly, the best outcomes for that person can only be achieved if we adjust the processes of decision making and action in health care in relation to that person's place in his or her society. Rather than expecting people with many personal and social differences to fit into standard healthcare services and systems, such adjustments can result in enhancing the efficacy of individual and societal health outcomes and producing more equitable and just health care for all. The gross inequalities in health that we see within and among countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and noncommunicable disease alike (Marmot, 2005). Many healthcare providers relate real-life stories of their sadness and frustration in dealing with healthcare issues arising from social problems. Clients also relate how they suffer from the effects of social and economic inequality, which exacerbates any health issues they may want or need to address. In the following case study, the cascading effect of life events can be seen to overwhelm a young mother and, as a result, her children.

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Case Study 19.1

Social Influences on Health Sally is being treated for clinical depression. She has spent significant periods of time in institutionalized care settings for people who have mental health issues. She has seen two psychiatrists and attended a number of group therapy programs aimed at helping her set achievable life goals including finding meaningful work. Her two children are currently cared for by their grandmother as Sally has been unable to provide a stable home environment for them. Sally left her physically abusive husband when her second child was 2 years of age. She had no paid employment and was unable to secure rental accommodation as the family had been blacklisted by real estate agents as a result of the damage to property caused by her husband in previous rentals. She now sleeps between two of her friends’ houses. She has become significantly overweight, a common side effect of the medication she has been prescribed. This has led to a further decrease in her self-esteem and has made it more difficult for her to be physically active. Her GP (general practitioner or primary care provider) has just told her that she is now prediabetic and must lose weight.

Social Determinants of Health Talking of social justice and client empowerment means that as practitioners we should see people as social beings, located within sociocultural contexts, relationships and systems, which work together in myriad ways (Lutfey Spencer and Grace, 2016), materially affecting people's physical, emotional, mental and spiritual health. As illustrated in the earlier example, it is clear that homelessness, unemployment, intimate partner abuse, loss and grief and health interventions themselves have affected Sally's current mental and physical health. Additionally, the sociocultural factors of gender and class have an already deep effect: You are more likely to experience intimate partner violence if you are a girl or woman. Women are more likely to be the primary carer for young children or to be in part-time or casual work, thus affecting their economic security and access to, and treatment within,

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appropriate healthcare contexts. These outcomes are also determined by class and gender (Lutfey Spencer and Grace, 2016; Solar and Irwin, 2010). Clinicians make gender-based decisions, albeit perhaps unconsciously, by making more sophisticated and determined efforts for men than women, even when they present with the same health condition. Society still gives more support to men when it comes to salary levels, employment and promotion but also, in health care, in the need to help men return promptly to well-being and employment to ‘take care of their families’. Female partners are expected to take on the main work of child care to accommodate this male privileging. Women who are ill are also more likely to be expected to carry on their family roles and their healthcare actions and responsibilities (for themselves and their children). This is particularly exacerbated if the woman does not have extended family support or is a single parent. Women are also more likely to be diagnosed as mentally ill when their real diagnosis is more to do with the experience of abuse or being excluded from access to material resources, such as somewhere to live (Alvarez-Dardet and Ruiz, 2000). A World Health Organization (WHO) Commission completed by the Women and Gender Equity Knowledge Network concluded that: Gender inequality damages the health of millions of girls and women across the globe. It can also be harmful to men's health despite the many tangible benefits it gives men through resources, power, authority and control. These benefits to men do not come without a cost to their own emotional and psychological health, often translated into risky and unhealthy behaviours, and reduced longevity. Taking action to improve gender equity in health and to address women's rights to health is one of the most direct and potent ways to reduce health inequities overall and ensure effective use of health resources (Sen and Östlin, 2007, p. xii). The provision of health services and healthcare relationships also occurs within a complex sociocultural context. For example, there is a large body of evidence that demonstrates how perceived social worth affects what health conditions are researched, what drugs get developed and how clinicians diagnose, treat and follow up

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patients (Australian Institute of Health and Welfare, 2016; Marmot et al., 2008; Wallerstein et al., 2011). Perceived social worth is determined by a number of factors such as employment status, relationship status, how a person physically presents in terms of body shape and clothing, if he or she has a drug and alcohol dependency or if he or she is part of the welfare system. These factors have been shown to construct what is known as provider and system bias. Taken to extremes, Sudnow (1967) found that ‘[o]verall, the lower the social standing of a patient, the lower the likelihood that the staff would exhaust all resuscitative options to save him or her. In many instances, patients of low social viability were declared dead in advance of their actual death’ (as quoted by Timmermans, 1998, in Lutfey Spencer and Grace, 2016, p. 108). A follow-up study by Timmerman (1998) revealed that resuscitation of people with drug and alcohol abuse histories was affected by staff's negative attitudes to that history – in contrast to resuscitations performed on people they knew to have greater community standing. Whether we like it or not, at times, treatment decisions and applications are based on stereotypes, prejudices and resulting acts of discrimination by providers and clinicians across the spectrum of health services.

Reflection Point 1 Consider your own clinical work experience. How have you encountered decision making or healthcare actions that demonstrate discrimination or lack of consideration of sociocultural differences among patients? Perhaps you have experienced such actions yourself as a patient or healthcare professional. How have these affected your approach to clinical decision making? Let's go back to Sally for a moment. If Sally were an indigenous person, her access to fair and equitable treatment would typically be further compounded, and her current health status would probably be even worse. In Australia, it is well recognized that the mental, spiritual and physical health of the indigenous peoples of this country is considerably worse than that of the nonindigenous

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population; it is also well recognized that Aboriginal and/or Torres Strait Islander people are among the most disadvantaged indigenous peoples in the developed world (World Health Organization, 2008). They experience lower levels of access to health services, and when they do access services, they are more likely to be hospitalized for treatment than the nonindigenous population (Australian Institute of Health and Welfare, 2016). Although hospitalization may appear to be positive and supportive, it fails to consider cultural concerns like family support and emotional stress at isolation. Dispossession, racism and lack of basic human rights directly affect mental, physical and spiritual wellbeing and health (Australian Bureau of Statistics, 2013; Australian Indigenous HealthInfoNet, 2016; United Nations Development Programme, 2003). Such inequalities generate a relationship of complex, compounding issues, which materially present in and on people's minds, spirits and bodies when they encounter the healthcare professional. [T]he social problems of the contemporary world walk into the clinician's office every day. The mundane details of the social determinants of health are writ small in our daily encounters with patients (The Editors, 2006, p. 2). Another such example comes from Canada. Adelson (2005) investigated health care in the First Nations (indigenous Canadian) populations and reported on the disproportionate burden of ill health and social suffering of these peoples. She argued ‘[i]n analyses of health disparities, it is as important to navigate the interstices between the person and the wider social and historical contexts as it is to pay attention to the individual effects of inequity’ (p. S46). Browne and Fiske (2001, p. 126) examined mainstream healthcare encounters from the perspective of First Nations women from a reserve community in northwestern Canada. The resulting narratives ‘revealed that women's encounters were shaped by racism, discrimination and structural inequities that continue to marginalize and disadvantage First Nations women. The women's health care experiences have historical, political and economic significance and are reflective of wider postcolonial relations that shape their everyday lives’.

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The situation of refugees is an extreme case of sociopolitical effects on health and well-being. Sharara and Kanj (2014, n.p.) draw attention to the health effect of Syria's ongoing civil war that has ‘displaced 6.5 million Syrians, left hundreds of thousands wounded or killed by violence, and created a vacuum in basic infrastructures that will reverberate throughout the region for years to come. Beyond such devastation, the civil war has introduced epidemics of infections that have spread through vulnerable populations in Syria and neighboring countries’. According to El-Khatib et al. (2013), around 3% of the world's population (214 million people) has, for various reasons, crossed international borders. They draw attention to Syria, which has, since March 2011, experienced a state of political crisis and instability resulting in an exodus of more than 1 million Syrian refugees to neighbouring countries (Lebanon, Jordan, Turkey, Egypt and North Africa). They call for the international community to support Syrian refugees and their host governments. The United Nations High Commissioner for Refugees (UNHCR) (2011) contends that refugee resettlement has the potential to serve as ‘an important expression of international solidarity and responsibility sharing’, providing international protection ‘to meet the specific needs of vulnerable persons whose life, liberty, safety, health, or other fundamental rights are at risk in the country where they have sought refuge’ (UNHCR 2011, from Ostrand 2015 p. 267). Health practitioners, governments and nations must recognize that social relations, structures and histories are different for all groups and affect our health and well-being, our access to and treatment within the health system and the decisions made by governments, healthcare organizations and professionals within that system. Social and economic inequity means that those who are disadvantaged experience disability, illness and death disproportionately more than people lucky enough to be protected by their social and economic situation. The study of these social determinants of health includes the conceptual and operational frameworks of the health system itself. If we are to achieve fair and just access to, and treatment within, healthcare systems and by healthcare professionals, then it is important to acknowledge the relationship among perceived social worth, health status and treatment. We need to work against

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discrimination and prejudice at systemic and individual levels. Understanding health and well-being from a social justice perspective can help healthcare professionals uncover hidden assumptions and resulting discriminatory interactions that result in systems and provider bias.

Reflection Point 2 What part has social justice played in your thinking about health care? Consider the concept and practice of duty of care. This is part of the core rhetoric, socialization and education of healthcare professionals. How much of our health care – at individual, organizational and national levels of provision – embodies social justice as part of our duty of care to the individuals and societies we claim to provide this care for?

Social Justice So what do we mean by a social justice framework, and what does it mean to work within such a framework? First, it means accepting that injustices do exist and that these affect people's health and well-being. It also means understanding that structural and everyday violence exists and that this too affects people's health and well-being, be it racism, homophobia, ableism or small acts of discrimination because a person does not meet our own moral standards. It means taking into account people's biopsychosocial contexts: where they live, the work (or lack of work) they do, the lives they lead, their histories and their place with/in sociocultural contexts. It means seeing Sally as more than a person needing to lose weight but as someone who needs help and support to find a secure place to live and work to pay the bill. And, it means working with her so that she can live with her own children. On a larger scale, it may mean putting money into researching drugs that do not cause weight gain for people who have depression. This is just one example of a healthcare strategy that might help one problem but cause others – and the patient ‘just has to live with it’. How do we take these strategies into account in our clinical reasoning? Hixon et al. (2013) argue that healthcare professionals must both

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recognize and understand that health is a fundamental human right and that healthcare professionals must pursue the goal of health for all, not just good health for some and not so good health for others. This stance is seen as quite radical in some countries, such as the United States, at present, but it nonetheless is an important aspirational goal for all: A commitment to social justice requires that we not limit our sense of justice simply to the more equitable provision of health care to those who are ill, but demands that we examine injustices in the distribution of health and the underlying reasons for unjust burdens of illness. (Hixon et al. 2013, pp. 161–162) This argument draws upon sociological and social psychological understandings of health and illness and the broader sociohistorical determinants of these. Known as social medicine, social epidemiology, or the social model of health, it is a potentially powerful corrective to the more recent reductionist approach to people where medical care has often been reduced to ‘efficient business practices [which] treat disease as though only isolated organ systems of sick individuals are involved’ (Hixon et al. 2013, p. 163). If we adopt a social justice orientation and accept that health is a social phenomenon and that we live in a word riddled with social injustices such as systemic marginalization and oppression, then we can privilege social concerns (see also Nikhil and Patel, 2015). This means that in our practice we understand that supporting Sally to achieve more control and self-determination in her life may be as, if not more, effective than putting her on a weight management program or that helping Sally lose weight will not be effective in the long run if she continues to be marginalized. A social justice orientation also means that we see gender-based violence as causal in Sally's current health and well-being status. This is quite a challenge to conventional thinking, where we treat the patient and the ‘problem’ they are immediately presenting with. Marginalized and oppressed people suffer the most in terms of health trajectories and treatment, and many people who suffer from certain health conditions are further oppressed and discriminated against, for example, those with mental illness or drug dependency. The World

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Health Organization Commission on Social Determinants of Health has articulated these relationships in its comprehensive assessment of global health inequities (Marmot et al., 2008). These ongoing and compounding injustices contribute to both the health and wellbeing of individuals or groups and also contribute to research priorities, health treatment availability and everyday interactions within the system.

Reflection Point 3 Do you have a viewpoint on social determinants of disease? Perhaps your education has led you to adopt a purely biomedical model of health and illness or a wellness model. Perhaps you work in a primary or tertiary healthcare setting or in community-based health care. Where does health as a social phenomenon fit into your current healthcare model and practice? There are two main branches of social justice that are relevant to consider here: distributive justice (Rawls, 1971) and deliberative justice (Young, 1990), and both can, and probably should, coexist. Distributive justice is primarily concerned with fair and equitable distribution of resources. In democratic nations, governments and systems are held responsible for this. The assumption is that everyone is entitled to basic human rights and a minimum standard of social goods and opportunities to achieve those social goods. This position is strongly embedded in many patient charters in hospitals; for instance, see Box 19.1. Within this distributive justice framework, each person is expected to be treated equally, and everyone is expected to be afforded the same degree of fairness, respect and dignity.

Box 19.1

Patient Charters Patient charters are statements by organizations (healthcare providers) pertaining to rights and responsibilities. The content of these charters varies. Ideally, they encompass rights and

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responsibilities for patients, the public and staff. An example of this is provided by the Mater Hospital, Queensland (http://www.mater.org.au/Home/For-Patients-and-Visitors/Patientrights-and-responsibilities). In summary it states: Mater respects your right to receive healthcare services. We are committed to provide exceptional, patient-focused, high-quality and safe healthcare. To provide such care, a partnership between patients, carers and families and healthcare providers is essential. The Mater Patient Charter addresses rights and responsibilities with regard to access, safety, respect, communication, participation, privacy and comment. The Patient Charter explains what you can expect from us and what we expect from you as we strive to provide you with the best possible care. Such charters potentially provide many benefits and simultaneously raise serious issues. For instance, charters of health responsibilities raise ethical tensions, such as whether patients’ responsibility for their own health might deny them health care (Schmidt, 2007). For further reading, see Darzi A., 2007. Our NHS, our future: NHS next stage review—interim report. Department of Health, London, UK. Deliberative justice enhances and extends distributive justice by exploring and understanding notions of social worth and the processes that enable individuals and groups to be valued, or devalued, within society and in everyday interactions. This is then extended to understand how social worth is perpetuated through marginalization, domination and exclusion from decision-making processes, sedimenting both advantage and disadvantage in our social systems and everyday lives (McLaughlin, 2009). Taking these two ideas together, the focus is then on putting in place laws, policies and practices to:

■ distribute the goods, resources and opportunities in society fairly, ■ challenge the processes that enable and perpetuate the domination and advantage of certain groups of people and their values, beliefs 464

and behaviours and ■ champion equity, self-determination, interdependence and social responsibility of marginalized groups and individuals (Aldorondo, 2007). These are not new ideas, but they do call for new practices and decision-making processes and behaviours in health care. Public health and health promotion, social work, radical psychiatry, critical public health or the new public health – critical psychology and liberation psychology – are all areas of clinical practice that have been leading the way in professional and systems change. Some branches of nursing and nursing scholarship have also embraced such ideas: We have come to realize that our nursing scholarship needs to look beyond individual experiences of health and illness to encompass the social foundations that determine health status to a large extent … Influenced by the realization of a society structured by discrimination and inequities, as well as legislated and public health policies that mandate equitable and accessible health care, nursing scholarship has begun to examine the role of the profession in fostering social justice (Kirkham and Anderson, 2002, p. 2). However, our experience is that this movement is frustratingly slow. One reason for this is that the health system itself is embedded in a larger social system, which struggles to realize social equity and justice. Another reason is the lack of social justice education and training for healthcare professionals and that current professionals find it difficult to make the link between social justice and their own individual practice. Many professionals seem unaware of their own taken-for-granted assumptions about the causes of health and well-being and their own place in perpetuating or challenging the status quo. Vera and Speight (2003) offer a useful set of guiding principles to synthesize deliberative social justice and professional practice. Although they focus on psychology and counselling, the synthesis is a useful one to consider across the

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health professions. They argue for an emancipatory practice, both as process and outcome, stating that ‘[i]dentifying the philosophies and professional roles that will most effectively promote the healthy development and well-being of oppressed groups is our ethical and moral obligation’ (2003, p. 270). Many of their guidelines echo what we have already discussed in this chapter in terms of holistic respectful approaches and understanding that health and illness are as much outcomes of social contexts and social worth as biology. What they add are some direct strategies that professionals can adopt in their practices. Other strategies inform day-to-day interactions with clients and patients and include not overemphasizing individual determination, as this is maintaining the status quo; using interventions that change individuals and social systems; engaging in community outreach such as facilitating support and care networks, and identifying community strengths and developing partnerships. They believe that ‘the professional's expertise may be better applied by helping to organize (e.g., encouraging the creation of, or joining with, grass-roots community organizations) or advocate (e.g., facilitating contacts with community leaders, policy makers, legislators, etc.) within the community’ (Vera and Speight 2003, p. 265). The Royal Australian College of General Practitioners (RACGP), in its 2016 curriculum guidelines for the education and training of Australian GPs in terms of Aboriginal and Torres Strait Islander peoples, wholeheartedly embraced the same guiding principles as discussed by Vera and Speight, firmly placing GPs at the forefront of the struggle for social justice. They state that a partnership approach (in terms of 1 : 1 interactions and between communities of clients and communities of practice) is more likely to lead to successful outcomes and that implementing a model of holistic health care that addresses the social determinants of health and the right to self-determination is essential. This change in current practice and decision making can be achieved, they believe, by the provision of education and training that promote relevant knowledge, skills and attitudes that enable respectful and appropriate treatment of people and the ability to advocate for health equity and associated health outcomes. Furthermore, by enacting the principles of deliberative justice, Aboriginal and Torres

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Strait Island peoples can be centrally involved in the development and delivery of such education and training (RACGP, 2016). This, we would argue, could be applied to all health education and training and all disadvantaged groups in our societies. All health and allied healthcare professionals need to have the knowledge and skills needed to provide holistic and useful care that does not perpetuate the current advantage/disadvantaged dichotomy.

Empowerment The World Health Organization Commission on Social Determinants of Health, referred to previously, calls for a global movement to address health inequities through political, civic and personal empowerment (Marmot et al., 2008). An understanding of the theory and application of empowerment is central to both the development of knowledge, skills and attitudes to advocate for, and operationalize, social justice in our healthcare interactions and systems and also to understand why this is, in fact, so difficult to realize. Central to empowerment is the concept of decision making by the people whose health we are talking about. This position has been taken up strongly by the disability sector with the slogan ‘nothing about us without us’ being an international rallying cry. This slogan foregrounds the notion that people with disabilities, who are routinely and systematically disempowered and marginalized, know what is best for them and must be included at all levels of decision making about their lives (Charlton, 2000). The implementation of such an idea has proved problematic because it requires a redistribution of power to the benefit of disadvantaged groups, especially in decision making (Labonte, 1994). This is challenging for healthcare professionals and the health system, as most health systems are hierarchical and authoritarian in nature and are designed with little or no participatory space for individuals and groups, other than those already in control (Pulvirenti et al., 2014). And although much policy rhetoric supports such ideas (e.g., Australia's National Chronic Diseases Strategy, where Principle 2 concerns growing a person's control over their own health) when it comes to policy implementation, support dwindles as those with the power cry ‘but we know best’. So, for example, if Sally was given control over

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deciding where she would like the health resources currently allocated to her to be spent, she might say securing somewhere to live, or having a mental health peer support person to work with to problem-solve everyday life, or any number of things that she believes would be useful for her health. If you asked her current GP to decide, he or she might say a series of dietitian appointments and attending a group-based weight-loss program. The term ‘empowerment’ is problematic and has historically been poorly defined (Finfgeld, 2004). It also presupposes the existence of a disempowered individual or group, which many challenge. However, a social justice and human rights–based approach to health empowerment is concerned with enabling disadvantaged and marginalized groups, who by definition are disempowered, to have the greatest control possible over their own health and the factors that influence their health. Conducive social conditions and practices that facilitate meaningful empowerment must be designed and operationalized to enable people to have a significant input into their own treatment and establishing the priorities of the system and advocating for resources. Empowering people by redesigning systems and practices will have a material effect on that group's health and well-being and is vital to influencing the social determinants of health and reducing health inequality. Empowerment understood in this way means a whole-of-systems approach where health interventions go beyond the clinic and into the community (Keleher, 2007; Greenhalg, 2009, in Pulvirenti et al., 2014, p. 306). It means professional, political and structural change, redistribution of resources and individual behaviour change by practitioners to tackle social injustice effectively. Such individual professional behaviour change may be seen in the model of Mindful Dialogical Relationships, enacted by community-based therapists for people with physical and cognitive impairments, where ‘some of the most efficient and effective ways to meet their clients’ complex needs are informal, fluid, organic and often not preprogrammed’ (De Bortoli et al., 2017, p. 102). This could include therapist participation in community-based sports organizations or liaison with local schools, councils or government departments with the aim of developing avenues of empowerment for people with impairments who can then more fully participate in their own local communities. Community activities can then

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become the inclusive living space needed for everyone living within that community. Such professional and personal efforts necessarily take place within communities, often where the professionals and clients involved may live together in the same community, allowing ongoing mindful, engaged and responsive relational development among people, first to include a person with special needs but gradually expanding community responses to become commonplace for other people within these communities. In the area of mental health, the relatively new implementation of the Recovery Model provides one example in which a whole of systems approach is being taken. The recovery movement has grown from recognition that people who have a mental illness want to be empowered (Leamy et al., 2011). This means that they want service providers to view them as whole people and to work collaboratively with them towards goals, discussing options and choices with respect. Here decision making and provision of treatment are also relationship based, promoting trust and empowering people with choice and control. Systems and procedures recognize that even those with complex needs have capacities, resilience and insight. There is recognition that these people are the experts in their own lives and illness. Care plans must be developed with the service users accepted as selfdetermining agents with rights, choice and expertise (Horsfall et al., 2016; Slade et al., 2012). This, we argue, is one such model that could inform the operationalizing of a social justice and empowerment framework across all health systems and domains.

Chapter Summary Vogel (2010, p. 109) argues that if we ‘scratch the surface of recent healthcare reform’ we will likely to find a commitment to ‘patientcentred care’, but we need to note that ‘beyond a general promise to put patients at the heart of health care decision-making, most nations are still in the early stages of defining concrete parameters for the delivery of patient-centred care’. At the heart of patientcentred care is patient empowerment and a commitment to genuine social justice and decision making that both champions and enables these processes and outcomes. The need for a social justice framework or perspective arises from

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the recognition that:

■ health and illness are determined socially and biologically, ■ health and illness are distributed inequitably throughout society and ■ access to fair and equitable treatment for illness is often determined by perceived social worth and social positioning. Reflection Point 4 Where do we go from here – as practitioners, patient advocate groups, educators, researchers, healthcare systems and society? What is your view?

References Adelson N. The embodiment of inequity: health disparities in Aboriginal Canada. Can. J. Public Health. 2005;96(Suppl. 2):S45–S61. Aldorondo E. Advancing Social Justice Through Clinical Practice. Routledge: London, UK; 2007. Alvarez-Dardet C, Ruiz MT. Rethinking the map for health inequalities. Lancet. 2000;356:S36. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012–13, table 19 (data cube). [Australian Bureau of Statistics, Canberra, ACT] 2013. Australian Indigenous HealthInfoNet. Summary of Aboriginal and Torres Strait Islander health, 2015. [Australian Indigenous ealthInfoNet, Perth, WA] 2016. Australian Institute of Health and Welfare (AIHW).

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Healthy futures: Aboriginal community controlled health services report card 2016, cat. no. IHW 171. [AIHW, Canberra, ACT] 2016. Browne AJ, Fiske J. First nations women's encounters with mainstream health care services. West. J. Nurs. Res.2001;23:126–147. Charlton JI. Nothing About Us Without Us: Disability, Empowerment and Oppression. University of California Press: Oakland, CA; 2000. Darzi A. Our NHS, our future: NHS next stage review— interim report. [Department of Health, London, UK. Viewed 1 June 2017; Available from] www.dh.gov.uk; 2007. De Bortoli T, Couch B, Tasker D. Therapy tales. Tasker D, Higgs J, Loftus S. Mindful Dialogues in Community-Based Healthcare. Sense Publishers: Rotterdam, The Netherlands; 2017. El-Khatib Z, Scales D, Vearey J, et al. Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan. Confl. Health. 2013;7:18–21. Finfgeld DL. Empowerment of individuals with enduring mental health problems: results from concept analyses and qualitative investigations. ANS Adv. Nurs. Sci.2004;27:44–52. Hixon AL, Yamada S, Farmer PE, et al. Social justice: the heart of medical education. Soc. Med.2013;7:161–168. Horsfall D, Carrington A, Paton J. Stories of recovery from the bush: unravelling mental illness, self and place, research report. [Western Sydney University, Sydney, NSW. Viewed 1 June 2017; Available from] http://researchdirect.uws.edu.au/islandora/object/uws:35379 2016.

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Keleher H. Empowerment and health education. Keleher H, MacDougall C, Murphy B. Understanding Health Promotion. Oxford University Press: Melbourne, VIC; 2007. Kirkham SR, Anderson JM. Postcolonial nursing scholarship: from epistemology to method. ANS Adv. Nurs. Sci.2002;25:1–17. Labonte R. Health promotion and empowerment: reflections on professional practice. Health Educ. Q.1994;21:253–268. Leamy M, Bird V, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br. J. Psychiatry. 2011;199:445–452. Lutfey Spencer K, Grace M. Social foundations of health care inequality and treatment bias. Annu. Rev. Sociol.2016;42:101–120. McLaughlin AM. Clinical social workers: advocates for social justice. Adv. Soc. Work. 2009;10:51–68. Marmot M. Social determinants of health inequalities. Lancet. 2005;365:1099–1104. Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372:1661–1669. Nikhil A, Patel NA. Health and social justice: the role of today's physician. AMA J. Ethics. 2015;17:894– 896. Ostrand N. The Syrian refugee crisis: a comparison of responses by Germany, Sweden, the United Kingdom, and the United States. J. Migr. Hum. Secur.2015;3:255–279. Pulvirenti M, McMillan J, Lawn S. Empowerment, patient centred care and self-management. Health Expect.2014;17:303–310.

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Rawls J. A Theory of Justice. Harvard University Press: Cambridge, MA; 1971. Royal Australian College of General Practitioners (RACGP). RACGP curriculum for Australian general practice: curriculum for Australian general practice 2016, Melbourne, VIC, RACGP. [Viewed 28 June 2017; Available from] https://www.racgp.org.au/Education/Curriculum; 2016. Ruger JP. Health and social justice. Lancet. 2004;364:1075–1080. Schmidt H. Patients’ charters and health responsibilities. Br. Med. J.2007;335:1187. Sen G, Östlin P. Unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it. [Final report to the WHO Commission on Social Determinants of Health, Women and Gender Equity Knowledge Network. Viewed 1 June 2017; Available from] http://cdrwww.who.int/social_determinants/resources/csdh_ 2007. Sharara SL, Kanj SS. War and infectious diseases: challenges of the Syrian Civil War. PLoS Pathog.2014;10:e1004438. Slade M, Adams N, O'Hagan M. Recovery: past progress and future challenges. Int. Rev. Psychiatry. 2012;24:1–4. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: social determinants of health, Discussion paper 2 (policy and practice). [World Health Organization, Geneva, Switzerland. Viewed 1 June 2017; Available from] http://www.who.int/sdhconference/resources/Conceptualfra ua=; 2010. Sudnow D. Passing on: The Social Organization of

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Dying. Prentice Hall, Englewood Cliffs: NJ; 1967. The Editors. Introducing social medicine. Soc. Med.2006;1:1–4. Timmermans S. Social death as a self-fulfilling prophecy: David Sudnow's ‘passing on’ revisited. Sociol. Q.1998;39:453–472. United Nations Development Programme. Human development reports 2003. [Viewed 27 October 2003; Available from] http://hdr.undp.org/en/content/humandevelopment-report-2003; 2003. United Nations High Commissioner for Refugees (UNHCR). UNHCR Resettlement Handbook. UNHCR: Geneva, Switzerland; 2011. Vera EM, Speight SL. Multicultural competence, social justice, and counseling psychology: expanding our roles. Couns. Psychol.2003;31:253– 272. Vogel L. International patient charters are often nonbinding or feature fuzzy metrics. CMAJ. 2010;182; 10.1503/cmaj.109-3342. Wallerstein NB, Yen IH, Syme SL. Integration of social epidemiology and community-engaged interventions to improve health equity. Am. J. Public Health. 2011;101:822–830. World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. [Commission on social determinants of health final report, executive summary. WHO, Geneva, Switzerland. Viewed 1 June 2017; Available from] www.who.int/social_determinants/thecommission/finalrepo 2008. Young IM. Justice and the Politics of Difference. Princeton University Press: New York, NY; 1990.

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20

Clinical Decision Making Across Orthodox and Complementary Medicine Fields Sandra Grace, Stephen Loftus

CHAPTER AIMS The aims of this chapter are to: ▪ discuss the implications for mainstream allopathic practitioners of the widespread use of complementary medicine among their patients, ▪ discuss the practice of person-centred care that takes into account patients’ illness experiences and values their healthcare preferences, ▪ explore alternative ways of thinking through clinical problems and provide specific examples and ▪ explore strategies for integrating alternative ways of thinking that

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combine the strengths of both mainstream allopathic medicine and complementary and alternative medicine.

KEY WORDS Complementary and alternative medicine Allopathic medicine Integrative medicine Evidence-based medicine Practice-based evidence

ABBREVIATIONS/ACRONYMS CAM Complementary and alternative medicine

Introduction The goal of clinical reasoning of all healthcare professionals is to identify and articulate patients’ health needs and to use specialized knowledge and skills to work out ways to help patients achieve optimal health. To state this seems straightforward and obvious, but it can be problematic. This is because in developed countries the dominant healthcare system is Western medicine, often referred to as allopathic medicine. It has been characterized as biomedical, pathology-driven, cure- or disease-oriented, based on the scientific method and using evidence that is predominantly empiricalanalytical (Capra, 1983; Hawk, 2005; Hayes, 2007). Foucault (1994) discussed the rise of allopathic medicine in terms of the ‘clinical gaze’ that focusses on a pathological view of the body, usually a dead body rather than a living person. From this allopathic viewpoint, health is seen simplistically as the absence of pathology. Once some pathology has been identified and removed, it is assumed that a patient is then automatically healthy. The problem is that this biomedical view has great difficulty articulating health and well-being. If we view health and the illness experience from

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other perspectives, it is clear that there are far more complex issues than a biomedical view assumes. For example, health, from the patient's viewpoint, has been described as a sense of ‘homelike being in the world’ (Svenaeus, 2000). Mainstream allopathic medicine is not naturally disposed to take the patient's viewpoint into account, as pathology does not need to know anything about a patient's sense of ‘being at home in the world’. This may be one reason why complementary and alternative medicine (CAM) approaches to health care are so popular with patients and people who are well. Advocates of CAM approaches claim that CAM practitioners pay far more attention to what the patient feels and says about his or her health (Berger et al., 2012). One way of summarizing these differences is to say that allopathic medicine has a disease focus (what the pathologist looks at), and CAM approaches focus on the illness experience (what the patient goes through). Likewise, allopathic medicine has tended to assume that health is simply absence of pathology, whereas CAM pays far more attention to developing the wellness of patients. There is often a much greater holistic view in CAM. As Reeve (an allopathic doctor) puts it: There is evidence within the complementary and alternative medicine (CAM) literature of individuals undertaking sophisticated and multidimensional assessments of health status and need. For some, explanations of ‘dis-ease’ within CAM frameworks make more sense of individual illness experiences than a pathological account. CAM users are not simply dissatisfied with conventional medicine, but make sophisticated assessments of their health needs and the appropriate therapeutic approach needed to address them, drawing on a range of knowledges to support this process (Reeve, 2010, p. 6). Clinicians’ views of legitimate health care are shaped by their education, personal experiences and their own health beliefs, which may be different from those of their patients. The diversity of views means that patients are often willing to call on a surprising range of what they see as health-promoting strategies, including selfdirected activities like physical exercise, meditation and CAM. CAM encompasses a broad domain of healing resources and

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approaches along with their accompanying theories, evidence and beliefs. The range of therapies is wide. Some of the most popular are acupuncture, chiropractic, homoeopathy, Western herbal medicine, naturopathy, massage therapy, hypnotherapy, traditional Chinese medicine and osteopathy. Many patients are enthusiastic about the use of CAM products like herbal and homoeopathic medicines and nutritional supplements (Armstrong et al., 2011; Reid et al., 2016). A significant step forward in our understanding of the prevalence of CAM occurred when Eisenberg et al. (1993) published a paper on the use of unconventional medicine in the United States. This paper reported that one-third of adults in the United States had used at least one unconventional therapy in the previous year, bringing into sharp focus ‘one of the most important health consumer trends of the 20th century’ (Andrews, 2004, p. 226). Similar growth in CAM use has been observed in other developed countries (Williamson et al., 2008). For example, it is estimated that over two-thirds of Australians use CAM, with AUD $4 billion national annual ‘out-of-pocket’ expenditure (Xue et al., 2007). It is also known that consumers often use CAM in conjunction with other health-promoting strategies, yet most patients do not tell their medical doctors (Eisenberg et al., 2001). Some studies have reported that fewer than 10% of women ask their doctor's advice about using CAM during pregnancy (Forster et al., 2006; Holst et al., 2009). Failure to disclose the totality of their health care to their health practitioners could be detrimental to patients who may be illinformed about safety risks associated with combining some herbal medicines and prescribed drugs. Hypericum perforatum (St. John's wort), for example, has been shown to reduce pharmaceutical effectiveness in a range of different drug classes (Hennessy et al., 2002; Mills and Bone, 2005; Pfrunder et al., 2003). A patient taking warfarin is at risk for increased bleeding if he or she is also taking gingko biloba, and a patient on hypoglycaemic therapy who takes Korean ginseng (Panax ginseng) is at risk for inadvertently altering his or her blood glucose levels (Harris et al., 2015). Given that such a large proportion of the population in Western countries uses CAM, it is important that allopathic medical practitioners have some understanding of all the health measures taken up by their patients. Even if the medical practitioners are

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opposed to CAM, they need to know something about the CAM services or products that their patients are using. Clinicians owe it to their patients’ health to be conversant with issues associated with the combination of CAM and allopathic medicine (Phelps, 2001). Beyond this, it can also be argued that all clinicians need to find and use anything and everything that can reasonably be expected to help their patients achieve optimal health (Saper, 2016), and this may include CAM. Person-centred care demands that clinicians focus on the patient, on the patient–practitioner relationship and on what works best for a particular patient at a particular time. Such a focus renders applying labels like ‘allopathic medicine’ and ‘CAM’ irrelevant (Cohen, 2004; Eisenberg, 1997). Ultimately, medicine has a single aim: to relieve human suffering. When measured against this benchmark, different therapies can be seen as either effective or ineffective rather than ‘orthodox’ or ‘unorthodox’. No single professional group has ownership of health, and the best healthcare requires a multidisciplinary approach (Cohen 2004, p. 646). Person-centred care also requires doctors to acknowledge and work with their patients’ preferences for health care. As patients gain greater knowledge of, and agency in, managing their health care, it is important to work with what patients know and want. Moreover, being aware of CAM approaches can give clinicians new ways of thinking through clinical problems.

Alternative Ways of Thinking Through Clinical Problems Practicing person-centred care means taking patients’ use of CAM into account, valuing their healthcare choices and being informed about them. This could mean that clinicians may have to learn different ways of thinking through clinical problems, based on CAM or collaborating with CAM practitioners in various ways. The dominant model of clinical reasoning in allopathic medicine is based on a technical rational approach that is grounded in biomedical science. The current dominance of evidence-based

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medicine is a good example of this technical rational approach. However, it is often forgotten that David Sackett, one of the pioneers of evidence-based medicine, made it clear that good clinical decision making required the integration of the best available evidence together with the expertise and experience of the clinician and the wishes and values of the patient (Sackett et al., 2000). If the patient is a passionate believer in the benefits of CAM, then this needs to be part of the clinical decision making that occurs. Because the technical rational approach has a poor vocabulary for articulating both the personal experience of clinicians and the wishes and value systems of patients, these aspects of clinical decision making are often ignored. This is a major reason for integrating the humanities and social sciences into the curriculum of many health professions. These disciplines have vocabularies and discourses that can enable health professions to think through these wider aspects of health care. In the same way, it can be argued that CAM approaches also open up our thinking about what our patients want, need and value so that we can adopt more than one perspective in our attempts to understand and help them. In Western medicine, biomedical and/or biopsychosocial practice models predominate, demonstrating the primacy granted to biomedical evidence. By contrast, CAM practitioners draw on a range of different practice models. For example, in homoeopathy most practitioners identify spiritual and energetic dimensions in a metaphysical model of diagnosis and treatment. Traditional Chinese medicine (TCM) interprets channels of energy or life force (Qi) as they traverse the body in 12 meridians. The underlying concepts of TCM are illustrated in Box 20.1.

Box 20.1

Underlying Concepts of Traditional Chinese Medicine (National Center for Complementary and Integrative Health, 2013)

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▪ The human body is a miniature version of the larger, surrounding universe. ▪ Harmony between two opposing yet complementary forces, called Yin and Yang, supports health, and disease results from an imbalance between these forces. ▪ Five elements—fire, earth, wood, metal and water— symbolically represent all phenomena, including the stages of human life, and explain the functioning of the body and how it changes during disease. ▪ Qi, a vital energy that flows through the body, performs multiple functions in maintaining health. Other CAM practices have evolved distinctive models of practice to assess and treat their patients. Australian osteopaths and naturopaths, for example, tend to see patients with complex problems who do not easily fit conventional disease patterns (Licciardone et al., 2005; Orrock, 2009). Such practitioners have had to be inventive and willing to embrace a wide range of aetiological and treatment possibilities. For example, in osteopathy, patients are initially assessed for red flags, but if a patient is deemed suitable for osteopathic care, attempts are made to make sense of the patient information by considering a range of practice models. Subjective information collected from patients and objective data from tests and examinations are considered in a context of connected functioning body systems, including biomechanical, biopsychosocial, energy-expenditure, neurological, nutritional and respiratory-circulatory (Table 20.1). It is worth noting that osteopathic medicine is now accepted as mainstream healthcare practice in some countries such as the United States. TABLE 20.1 Diagnostic Models Used in Osteopathic Medicine (Kuchera and Kuchera, 1994) Biomedical

Biomechanical

Consideration of signs and symptoms in the context of defined diseases and a need for referral for further medical assessment and management (red flags). This is similar to any primary care practitioner. Assessment of the health of the musculoskeletal system, including how the structure (posture) and function are

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integrated. This is similar to other manual medicine practices and is primarily a mechanical/orthopaedic approach. Biopsychosocial Consideration of the psychosocial factors influencing the patient's health, including relational, occupational and financial, and the need for multidisciplinary care. (Mainstream allopathic medicine is now starting to adopt a more biopsychosocial position.) Energy expenditure Assessment of whether the patient has optimal energy utilization and consideration of issues that may affect the healing process (e.g., relatively minor mechanical or immune dysfunctions). Neurological Assessment of function in the central, peripheral and autonomic nervous systems and the relationship of those systems to all tissues of the body. Nutritional Foundational dietary analysis for signs of deficiency or suboptimal nutritional status. Respiratory/circulatory Examination of the respiratory mechanism–ensuring that the function of breathing is optimal. Assessment of all tissues of the body for full blood supply and drainage. Assessment of the structural and functional relationship between the two systems.

Bortoft (2012) refers to diversity in unity to emphasize the multiplicity of parts that underpins a holistic view of the world. CAM approaches offer a way to be holistic and at the same time make the most of diverse approaches. Another CAM approach is that of energetic or vibrational medicine that takes account of critical events in the patient's life reasoning that emotional trauma may affect the patient's physical health. An ‘energetic healer’ described her diagnostic process in the following example: A patient came in. She had had ulcerative colitis for 10 years. She was 26. It started at 16. She had medical treatment, but it was getting worse, not responding. Before it started, she was fine. I said, ‘What happened at 16?’ She broke down crying, and she told me the whole story. Her grandmother was a control freak, commanding the whole household, having arguments with everyone. And she said, ‘I had a big argument with my grandmother one night, and the next day my grandmother suicided’. So she took all the guilt. Guilt effects the large intestine. I used psychotherapy because that's the quickest way to deal with this, and then we did acupuncture. Ten

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years of treatment and nobody had asked her what happened at the time her troubles started. Nobody checked why she had the problem. They were just treating the symptoms (CAM practitioner).

Integrating Alternative Ways of Thinking With the Thinking of Mainstream Allopathic Medicine Fundamental differences between the underlying philosophies of allopathic medicine and CAM are cited by many as the main barrier to their integration. These differences include the traditional reductionist, mechanistic approach of biomedicine as opposed to the more biocultural approach of CAM. Allopathic medicine has a focus on eliminating the disease-producing agent as opposed to CAM's focus on encouraging the innate ability of the human body to restore itself to health, and although allopathic medicine tends to have a focus on disease, CAM's focus is more on wellness (Capra, 1983; Nahin and Straus, 2001). If one adopts a strictly allopathic pathological focus, then all CAM approaches are likely to be dismissed as unsound and unscientific. However, there are now attempts to reconcile CAM approaches with allopathic medicine, evident strongly in the integrative medicine movement that is expanding globally.

Models of Integration Three different relationships between allopathic medicine and CAM have been described: pluralism, harmonization and full integration (Lewith and Bensoussan, 2004) (Fig. 20.1).

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FIG. 20.1 Models of integration.

Pluralism Pluralism refers to contrasting systems operating alongside one another with mutual respect but little or no interaction. Given the unbridgeable epistemological (i.e., knowledge determination) differences that are sometimes described between CAM and allopathic medicine, this model of parallel systems seems realistic and achievable even for the allopathic practitioners who are opposed to CAM.

Harmonization In this model, allopathic medicine and CAM practitioners work together but with no predetermined agenda or bias. Referral may occur between systems but does not need to be the result of a planned collaboration. Such an arrangement has been described by many CAM practitioners working in allopathic medical centres (Grace, 2009; Hunter, 1993). They have described moving from ‘in principle approval’ to acceptance as the medical practitioners

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became aware of their skills and scopes of practice. In such cases, medical practitioners have come to understand and appreciate the therapeutic benefits of CAM practices. These CAM practitioners have become part of the healthcare team without any formal collaboration.

Integration Within the model of integration, there are two dominant submodels in the literature: 1. Selective incorporation of evidence-based CAM into allopathic medicine Integrative practice in which allopathic medical practitioners act as primary contact clinicians (with subsequent referral to other providers) appears to be a common practice model in many areas (Grace and Higgs, 2010; Hollenberg, 2006; Shuval et al., 2002). In this model, allopathic medical practitioners are responsible for diagnosis and coordination of healthcare plans. The Australian Government's Enhanced Primary Care system, for instance, recognizes this model in its subsidizing of chiropractic, osteopathy, podiatry, psychology and other allied health treatments for patients with chronic health conditions. Subsidies are available only if the services are part of enhanced care plans and are supervised by allopathic medical practitioners (Health and Aged Care, 2004). 2. Selective fusion of the most effective elements of both CAM and allopathic medicine based on health outcomes The ideal model described by Lewith and Bensoussan (2004) is a selective fusion of the most effective elements of CAM and allopathic medicine for the optimal health outcomes for patients. Both biomedical evidence and clinical efficacy are valued. In this model, CAM and allopathic medicine are seen as complementary, and CAM practitioners and members of the allopathic medical profession become coworkers with equal input and standing.

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Integrated Clinical Reasoning There is increasing recognition that some allopathic clinicians readily embrace complementary approaches and have been extensively educated in both allopathic and CAM approaches (Loftus, 2009). The usual practice is to follow standard allopathic protocols with all patients to begin with and ensure there is no pathology (red flags) that should be dealt with by conventional means. There is a clear preference for using the strengths of allopathic medicine to begin with. If there are no red flags or if allopathic medicine fails, as it can do, especially in some chronic conditions such as chronic pain, these clinicians may then resort to a CAM approach. For example, one allopathic doctor who had extensive training and experience of acupuncture spoke in terms of taking one thinking hat off and putting on another (S. Loftus, 2006, pers. comm.). This same doctor also related that while undergoing the training in acupuncture, he and his other medical colleagues would regularly try to ‘translate’ what they were seeing and doing in the acupuncture clinic into allopathic terms. After several months of trying this, they eventually gave up and concluded that this translation was not realistic. The two ways of conceptualizing the body, health and disease were essentially incompatible. However, this did not dissuade these clinicians from using both allopathic medicine and acupuncture. This can be seen as a form of practicing the pluralism mentioned earlier. The two forms are happily used side by side but are not integrated in any deep way.

Reflection Point 1 Reflection on clinical reasoning of a general medical practitioner who practices both allopathic medicine and CAM: ‘I'm certainly aware of the idea that certain facts, certain concepts derive from homoeopathic ideas and certain others derive from what is common mainstream medical thinking. Within my mind these are contained within one sphere of understanding of the world. It's not so much a matter of jumping from one to the other as it is trying to appreciate what that globe actually is from any particular vantage point I happen to be looking at it from, and then

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comparing in my mind which pathways are going to be most useful at that point in time. Some of the more difficult decisions are to do with if I follow one route, if I give this patient an antibiotic now, how will that influence the information gathering that I need to prescribe a homoeopathic remedy that I've been trying to offer for some time? I'm trying to project outcomes based on different interventions and what's going to be most useful for the patient using different possible ways of going about it and whether it's reasonable, perhaps, to use both systems of medicine at the same time. One has to think about a number of factors in making that decision – whether the patient's going to be in close contact with you, how that influences what the best thing to do is. It's rare that the different interventions open to me are in direct competition. It's more a matter of trying to decide what's going to be most useful at any point in time.’ Readers – What do you think of these arguments and approaches? An important challenge facing clinicians in the future is to explore ways in which allopathic medicine and CAM might become integrated in a rigorous manner that respects the strengths of both without jeopardizing the rational foundations of either. It is said we live in a postmodern world, and perhaps the integration of CAM is part of what it means to have postmodern health care. Modernism is the view, now largely discredited, that there is only one (scientific) way to view anything. This view is exemplified in health care by the dominance of biomedical allopathic medicine. A postmodern view accepts that there can be multiple perspectives on anything. The inadequacies of allopathic medicine are evident in the dissatisfaction that many people experience with conventional health care in general and its failure to provide satisfactory solutions to chronic conditions in particular. This is one of the main reasons why so many people turn to CAM. The other big reason, of course, is that patients want to actively pursue a wellness agenda in their health care and lifestyles. Therefore, we need to find new ways of conceptualizing and carrying out the care we provide. One step that has been taken in this direction is the development of practice-based evidence. Clinicians can develop new knowledge from their experience of practice itself. There is a realization that the

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balance between theory and practice is not all one way (that is, from theory to practice) but can be bidirectional. This raises the important questions of how evidence from practice can be theorized, how it is theorized in different systems of thought, and how these systems of thought can inform each other. We can take some lessons from the literature on communities of practice. There are well-known cases where people have had the courage and insight to be boundary crossers between different communities of practice. For example, Erwin Schrödinger (1947) wrote a book that brought together physicists and biologists, two groups who previously had little in common. Schrödinger was able to persuade the two groups that they did in fact have a great deal in common, and his work is now seen as the start of a new and very successful community of practice, that of molecular biology. Perhaps what we need now are people who are well informed about allopathic medicine and CAM and who can explore ways to bridge the gaps between them. Even if no new community of practice is formed, there is always the chance of cross-fertilization of ideas to the benefit of all concerned. The integrated clinical reasoning they undertake will emphasize holism and multiple ways of thinking and knowing together with what the patient values and brings to the clinical encounter (Fig. 20.2).

FIG. 20.2 Integrated clinical reasoning.

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Chapter Summary In this chapter, we have explored a number of arguments:

▪ The attraction of CAM to health consumers has been attributed to its much more holistic approach to health care than the more narrow and conventional pathological account of diseases found in allopathic medicine. CAM can focus more on a patient's sense of ‘dis-ease’. ▪ CAM offers alternative ways of clinical reasoning and thinking through clinical problems. ▪ Despite traditional epistemological differences, various collaborations between allopathic medicine and CAM have been developed in many Western countries. Such collaborations provide opportunities to create new practice knowledge, out of which can arise new practice epistemologies based on understanding of how this practice knowledge arises, is used and is developed. Individual clinicians within these collaborations both acquire practice knowledge and contribute to it. ▪ A distinctive characteristic of the clinical reasoning and practice epistemology of integrative medicine is the emphasis on holism and multiple ways of thinking and knowing together with what the patient values and brings to the clinical encounter.

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Osteopathic Association: part 1—the practitioners. Int. J. Osteopath. Med.2009;12:14–24. Pfrunder A, Schiesser M, Gerber S, et al. Interaction of St John's Wort with low-dose oral contraceptive therapy: a randomized controlled trial. Br. J. Clin. Pharmacol.2003;56:683–690. Phelps K. AMA discussion paper: complementary medicine. J. Austr. Integr. Med. Soc.2001;4. Reeve J. Interpretive medicine: supporting generalism in a changing primary care world. Royal College of General Practitioners, Occasional paper 88. 2010. Reid R, Steel A, Wardle J, et al. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement. Altern. Med.2016;16:176. Sackett DL, Straus SE, Richardson WS, et al. Evidencebased Medicine: How to Practice and Teach EBM. Churchill Livingstone: Edinburgh; 2000. Saper R. Integrative medicine and health disparities. Global Adv. Health Med.2016;5:5–8. Schrödinger EC. What Is Life? The Physical Aspect of the Living Cell. Cambridge University Press: Cambridge; 1947. Shuval JT, Mizrachi N, Smetannikov E. Entering the well-guarded fortress: alternative practitioners in hospital settings. Soc. Sci. Med.2002;55:1745–1755. Svenaeus F. The Hermeneutics of Medicine and the Phenomenology of Health: Steps Towards a Philosophy of Medical Practice. Kluwer Academic: Dordrecht; 2000. Williamson M, Tudball J, Toms M, et al. Information Use and Needs of Complementary Medicines Users. National Prescribing Service: Sydney; 2008. Xue C, Zhang A, Lin V, et al. Complementary and

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alternative medicine use in Australia: a national population-based survey. J. Altern. Complement. Med.2007;13:643–650.

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SECTION 4

Clinical Reasoning and The Professions OUTLINE 21 Clinical Reasoning in Medicine 22 Clinical Reasoning in Nursing 23 Clinical Reasoning in Physiotherapy 24 Clinical Reasoning in Dentistry 25 Clinical Reasoning in Occupational Therapy 26 Clinical Decision Making in Emergency Medicine 27 Clinical Decision Making in Paramedicine 28 Clinical Decision Making in Optometry 29 Clinical Reasoning in Dietetics 30 Clinical Reasoning in Pharmacy

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21

Clinical Reasoning in Medicine Alan Schwartz, Olga Kostopoulou

CHAPTER AIMS The aims of this chapter are to: ■ describe the process of diagnostic reasoning in medicine, ■ compare problem-solving and decision-making approaches to research on clinical reasoning and diagnostic error, ■ introduce dual-process models of reasoning and ■ explain educational implications of dual-process theory.

KEY WORDS Decision making Problem solving Dual-process theory Bayes’ theorem Hypothesis testing

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Pattern recognition

ABBREVIATIONS/ACRONYMS EBM Evidence-based medicine

Introduction How do physicians solve diagnostic problems? What is known about the process of diagnostic clinical reasoning? Why might a diagnosis be missed? In this chapter, we sketch our current understanding of answers to these questions by reviewing the cognitive processes and mental structures employed in diagnostic reasoning in clinical medicine. We will not consider the parallel issues of selecting a treatment or developing a management plan. For theoretical background, we draw upon two approaches that have been particularly influential in research in this field: problem solving and decision making. Problem-solving research has usually focussed on how an illstructured problem situation is defined and structured (normally by generating a set of diagnostic hypotheses) and is exemplified in the work of Elstein et al. (Elstein, 2009; Elstein et al., 1978), Bordage et al. (e.g., Bordage, 1994) and Norman (2005). Psychological decision research (also known as ‘behavioural decision making’) has typically looked at factors affecting diagnosis or treatment choice in well-defined, tightly controlled situations, as illustrated in the work of Kahneman et al. (Kahneman et al., 1982), Kahneman (2003) and Schwartz and Bergus (2008). A common theme in both approaches is that human rationality is limited or ‘bounded’. Nevertheless, researchers within the problem-solving paradigm have concentrated on identifying the strategies of experts in a field of medicine, with the aim of facilitating the acquisition of these strategies by learners. Behavioural decision research, on the other hand, contrasts human performance with a normative statistical model of reasoning under uncertainty. It illuminates cognitive processes by examining people's inherent reasoning tendencies (cognitive heuristics) and the associated reasoning errors (cognitive biases) to which even experts are not immune. As a way of improving human reasoning, this literature concentrates on

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debiasing and decision aids.

A Common Basis: Dual-Process Theory Both medical problem-solving and decision-making research have adopted dual-process or ‘two systems’ accounts of cognition described (with variations in details) by Kahneman (2003), Stanovich and West (2000) and, perhaps most accessibly, by Kahneman (2011). These accounts posit two distinct cognitive systems or types of processing. System 1 is a fast, automatic and intuitive mode of thinking that shares similarities with perception. Judgements made using System 1 take advantage of the power of pattern recognition, emotional cues and a set of cognitive heuristics and are susceptible to associated biases and the effect of the emotional state of the judge and emotional content of the judgement. System 1's accuracy is contingent on interactions among the features of the task and the judge's prior experiences and memories. System 2 is a slow, effortful, analytic mode that applies rules in an emotionally neutral manner (Fig. 21.1, from Kahneman, 2003). When appropriate data are available, System 2 yields the most normatively rational reasoning, but it is easily disrupted by high cognitive load. Therefore both systems can lead to error under different conditions. Dual-process theory is broadly accepted among psychologists, with variations focussing on when and how the two systems activate and interact with one another, differences in how experts and novices rely on each system and conditions under which each system is expected to provide better performance.

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FIG. 21.1 Effect on problem-solving strategy of case

difficulty, clinician experience and case features. (From Kahneman, D., 2003. Maps of bounded rationality: a perspective on intuitive judgement and choice. In: Frangsmyr, T. (Ed.), Les Prix Nobel: The Nobel Prizes 2002. Stockholm, Sweden, Almqvist & Wiksell International, pp. 416–499, with permission from The Nobel Foundation.)

Reflection Point 1 Reasoning operates simultaneously through dual processes: a fast, intuitive process (System 1) and a slow, analytical process (System 2).

Problem Solving: Diagnosis as Hypotheses Generation and Selection To solve a clinical diagnostic problem means first to recognize a malfunction and then to set about tracing or identifying its causes. The diagnosis is thus an explanation of disordered function and, where possible, a causal explanation. In most cases, not all of the information needed to identify and explain the situation is available in the early stages of the clinical encounter. Physicians must outline potential diagnoses (a ‘differential diagnosis’), consider their likelihood and severity and decide what information to collect, which aspects of the situation need attention and what can be safely set aside. Thus data collection is both sequential and selective. Experienced physicians often go about this task almost automatically, sometimes very

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rapidly; novices are slower and collect more information. There are several likely reasons for this. For example, novices may generate more diagnostic hypotheses on average than experts, or they may generate less appropriate diagnostic hypotheses that do not help them reduce the ‘problem space’ quickly; they may experience greater uncertainty and think that more information may reduce this; or they may lack efficient strategies for information search.

The Hypothetico-Deductive Method Early Hypothesis Generation and Selective Data Collection In their pioneering studies on clinical reasoning, Elstein et al. (1978) found that diagnostic problems are solved by a process of generating a limited number of hypotheses, or problem formulations, early in the workup and using them to guide subsequent data collection and integration. Each hypothesis can be used to predict what additional findings ought to be present if it were true. The workup is then a guided search for these findings; hence, the method is hypothetico-deductive and based on System 2 processes. Elstein et al. ascertained the universality of the hypothetico-deductive method in diagnostic problem solving: Novices and experienced physicians alike attempt to generate hypotheses to explain clusters of findings, although the content of the experienced group's productions is of higher quality. Other clinical researchers have concurred with this view (Kuipers and Kassirer, 1984; Nendaz et al., 2005). It has also been favoured by medical educators (e.g., Kassirer and Kopelman, 1991), but the emergence of dual-process theory has redirected interest towards System 1 processes in hypothesis generation, with many authors and practitioners claiming that they lead to better diagnosis, at least in expert clinicians.

Data Collection and Interpretation Data obtained must be interpreted in the light of the hypotheses being considered. A clinician could collect data quite thoroughly but could nevertheless ignore, misunderstand or misinterpret a

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significant fraction. In contrast, a clinician might be overly economical in data collection but could interpret whatever is available quite accurately. Elstein et al. (1978) found no statistically significant association between thoroughness of data collection and accuracy of data interpretation. Although studies based on medical record reviews have often attributed diagnostic failures to inadequate data collection (e.g., Singh et al., 2007), experimental research has not found a strong association between thoroughness of data collection and accurate judgement or diagnosis (Kostopoulou et al., 2017a). Investigators in the problem-solving tradition have asked study participants to think aloud while problem solving and have then analyzed their verbalizations and their data collection (Elstein et al., 1978; Kostopoulou et al., 2017b; Nendaz et al., 2005; Neufeld et al., 1981). Considerable variability in acquiring and interpreting data has been found, increasing the complexity of the research task. Consequently, some researchers switched to controlling the data presented to participants, to concentrate on data interpretation and problem formulation (e.g., Kuipers et al., 1988). Controlling the presentation of data facilitates analysis at the price of fidelity to clinical realities. This strategy is the most widely used in current research on clinical reasoning, the shift reflecting the influence of the paradigm of decision-making research. Sometimes clinical information is presented sequentially to participants so that the case unfolds in a simulation of real time, but the participant is given few or no options in data collection (e.g., Kostopoulou et al., 2012; Nurek et al., 2014). The analysis can focus on memory organization, knowledge utilization, data interpretation or problem representation (e.g., Bordage, 1994; Groves et al., 2003). In other studies, clinicians are given all the data at once and asked to make a diagnostic or treatment decision (e.g., Sirota et al., 2017). Weiner et al. (Weiner et al., 2010, 2013) used unannounced standardized patients (actors presenting as patients incognito to physicians) and real patients carrying concealed audio recorders to demonstrate several important features of diagnostic decision making. These included failure to probe for information and identify diagnoses based in patient context rather than physiology (Weiner et al., 2010, 2013) and greater attention to case features identified by physician activity rather than those features revealed spontaneously by

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patients (Schwartz et al., 2016).

Case Specificity Problem-solving expertise varies greatly across cases and is highly dependent on the clinician's mastery of the particular domain. Differences among clinicians are to be found more in their understanding of the problem and their problem representations rather than in the reasoning strategies employed (Elstein et al., 1978). Thus it makes more sense to talk about reasons for success and failure in a particular case than about generic traits or strategies of expert diagnosticians.

Reflection Point 2 Reasoning depends on knowledge and the structure of knowledge in memory. General ‘reasoning skills’ may result in different outcomes depending on the experiences stored in the reasoner's memory.

Diagnosis as Categorization or Pattern Recognition The finding of case specificity also challenged the hypotheticodeductive model as an adequate account of the process of clinical reasoning. Patel et al. (e.g., Eva et al., 1998; Groen and Patel, 1985) pointed out that the clinical reasoning of experts in familiar situations frequently does not display explicit hypothesis testing. It is rapid, automatic and often nonverbal. Expert reasoning in familiar situations looks more like a System 1 process of pattern recognition or direct automatic retrieval from a well-structured network of stored knowledge (Groen and Patel, 1985). Because experienced clinicians have a better sense of clinical realities and the likely diagnostic possibilities, they can also more efficiently generate an early set of plausible hypotheses to avoid fruitless and expensive pursuit of unlikely diagnoses. The research emphasis thus shifted from the problem-solving process to the organization of knowledge in the long-term memory of experienced

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clinicians. Unlike hypothetico-deduction, pattern recognition and matching approaches do not require, or assume, that causal reasoning takes place. Expert–novice differences are partly explicable in terms of the size of the knowledge store of prior instances available for pattern recognition. This theory of clinical reasoning has been developed with particular reference to pathology, dermatology and radiology, where the clinical data are predominantly visual. Additionally, better diagnosticians are thought to have more diversified and abstract links between clinical features or aspects of the problem (Bordage, 1994). Experts in a domain are more able to relate findings to each other and to potential diagnoses and to identify what additional findings are needed to complete a picture (Elstein et al., 1993). These capabilities suggest that more experienced physicians are working with more abstract representations and are not simply trying to match a new case to a specific previous instance. However, such a matching process may still occur with simple cases (where there is a larger store of specific memories) or with cases that are somehow memorable, because matching would be quicker than abstraction.

Multiple Reasoning Strategies Norman et al. (1994) found that experienced physicians used a hypothetico-deductive strategy with difficult cases only. When a case is perceived to be less challenging, quicker and easier methods are used, such as pattern recognition or feature matching. Thus controversy about the methods used in diagnostic reasoning can be resolved by positing that the method selected depends on the perceived characteristics of the problem. Furthermore, there is an interaction between the clinician's level of skill and the perceived difficulty of the task (Elstein, 1994). Easy cases are solved by pattern recognition and going directly from data to diagnostic classification – what Groen and Patel (1985) called forward reasoning. Difficult cases need systematic hypothesis generation and testing. Whether a problem is easy or difficult depends in part on the knowledge and experience of the clinician who is trying to solve it (Fig. 21.2). At the same time, perceived difficulty can be manipulated: Mamede et al. (2008) suggested to study participants that some clinical cases had been previously seen by experienced physicians who had failed to

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diagnose them. The researchers found that cases perceived as difficult took longer to diagnose and were diagnosed more accurately than those perceived as straightforward. Using thinkaloud strategies, they also found more frequent mentions of findings, causal mechanisms and diagnoses for the supposedly difficult cases, suggesting that participants were using an analytical rather than intuitive approach for those cases.

FIG. 21.2 Characteristics of two cognitive systems for

judgement. (From Kahneman, D., 2003. Maps of bounded rationality: a perspective on intuitive judgement and choice. In: Frangsmyr, T. (Ed.), Les Prix Nobel: The Nobel Prizes 2002. Stockholm, Sweden, Almqvist & Wiksell International, pp. 416– 499, with permission from The Nobel Foundation.)

Dual-process accounts support the value of multiple reasoning strategies, particularly when different strategies (e.g., pattern recognition and hypothetico-deduction) may bring to bear the power of Systems 1 and 2, respectively.

Decision Making: Diagnosis as Opinion Revision In the literature on medical decision making, reaching a diagnosis is conceptualized as a process of reasoning about uncertainty in a statistical manner and updating an opinion with imperfect

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information (the clinical evidence). As new information is obtained, the probability of each diagnostic possibility is continuously revised. Each posttest probability becomes the pretest probability for the next stage of the inference process. Bayes’ theorem, the formal mathematical rule for this operation, states that the posttest probability is a function of two variables, pretest probability and the strength of the new diagnostic evidence. The pretest probability can be either the known prevalence of the disease or the clinician's belief about the probability of disease before new information is acquired. The strength of the evidence is measured by a likelihood ratio, the ratio of the probabilities of observing a particular finding in patients with and without the disease of interest. This framework directs attention to two major classes of errors in clinical reasoning: errors in a clinician's beliefs about pretest probability and errors in assessing the strength of the evidence. Bayes’ theorem is a normative rule for diagnostic reasoning; it tells us how we should reason, but it does not claim that we actually revise our opinions in this way. Indeed, from the Bayesian viewpoint, the psychological study of diagnostic reasoning centres on errors in both components, which are discussed later in the chapter.

Case Study 21.1

Screening Mammography Screening mammography for breast cancer has an overall likelihood ratio of about 9 for a positive test: The odds of breast cancer are about nine times higher in a woman with a positive mammogram than a woman with a negative mammogram (Breast Cancer Surveillance Consortium, 2013). How likely is it that an average adult woman who gets a positive mammogram actually has breast cancer? What if she is younger than 40 years of age? A Bayesian reasoner, considering a pretest breast cancer probability of 0.1% (1 breast cancer per 1000 women, or 1 : 999 odds), should conclude that a woman with a positive mammogram will have about a 1% posttest probability of breast cancer. In a woman younger than 40 years of age, however, not only is the pretest probability lower than average (closer to .005%, or 5 breast cancers per 100,000 women), but the likelihood ratio of a positive test is

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lower (closer to 5). As a result, a positive test in a young woman suggests a 0.02% probability of breast cancer. How accurate was your estimate of the posttest probability, the pretest probability and the strength of the test? The revision of opinion, using Bayes’ theorem, underlies teaching about diagnosis in evidence-based medicine (EBM) (Straus et al., 2010). A variety of paper and online tools and spreadsheets have been developed to provide decision support or simplify EBM calculations. A typical example is the graphical Bayesian nomogram, which permits quick calculation of posterior probabilities from prior probability and likelihood ratio information. Fagan (1975) published the best-known nomogram, which is widely available on a pocket-sized card. Schwartz (1998) provides a widely used online version.

A Common Challenge: Diagnostic Error Diagnostic error has attracted considerable interest in recent years due, in large part, to the patient safety movement. The US National Academy of Medicine (National Academies of Sciences, Engineering and Medicine, 2015) concluded that ‘most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences’ (p. 1). Estimates of the number of deaths that might be a result of diagnostic errors are alarming (Graber, 2013). Furthermore, in acute care settings such as general practice, accident and emergency and after-hours care, diagnostic error accounts for the majority of litigation cases (Gandhi et al., 2006; Silk, 2000). Graber et al. define diagnostic error as a ‘diagnosis that was unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made), as judged from the eventual appreciation of more definitive information’ (Graber et al., 2005, p. 1493). Similarly, and more concisely, Singh et al. (2014) define it as ‘a missed opportunity to make a timely or correct diagnosis based on the available evidence’. The Committee of the

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National Academy of Medicine (National Academies of Sciences, Engineering, and Medicine, 2015) proposed a more patient-centred definition: ‘the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient’ (p. 85).

Errors in Hypothesis Generation and Restructuring Neither pattern recognition nor hypothesis testing is an error-proof strategy, nor is either always consistent with statistical rules of inference from imperfect information. Kassirer and Kopelman (1991) illustrated and discussed errors that can occur in difficult cases in internal medicine, and Graber et al. (2002) reviewed classes of error. Because so much depends on the interaction between patient and clinician, prescriptive guidelines for the proper amount of hypothesis generation and testing are still unavailable for the student clinician and probably never will be. Perhaps the most useful advice is to emulate the hypothesis-testing strategy used by experienced clinicians when they are having difficulty, because novices will experience as problematic many situations that the former solve by routine pattern-recognition methods. In an era that emphasizes cost-effective clinical practice, routinely gathering data unrelated to diagnostic hypotheses should be discouraged. Many diagnostic problems are so complex that the correct solution is not contained within the initial set of hypotheses. Restructuring and reformulating must occur through time, as data are obtained and the clinical picture evolves. Ideally, one might want to work purely inductively, reasoning only from the facts, but this strategy is never employed because it is inefficient and produces high levels of cognitive strain (Elstein et al., 1978). It is much easier to solve a problem where some boundaries and hypotheses provide the needed framework. On the other hand, early problem formulation may also bias the clinician's thinking (Voytovich et al., 1985). Errors in interpreting the diagnostic value of clinical information have been found by several research teams (Elstein et al., 1978; Kostopoulou et al., 2009).

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Errors in Data Interpretation The most common error in interpreting findings is overinterpretation: Data that should not support a particular hypothesis, and that might even suggest that a new alternative be considered, are interpreted as consistent with hypotheses already under consideration (Elstein et al., 1978; Kostopoulou et al., 2009). The data best remembered tend to be those that support the hypotheses generated (Arkes and Harkness, 1980). Where findings are distorted in recall, it is generally in the direction of making the facts more consistent with typical clinical pictures. Positive findings are overemphasized, and negative findings tend to be discounted. From a Bayesian standpoint, these are all errors in assessing the diagnostic value of information, i.e., errors in subjective assessments of the likelihood ratio. These errors are thought to arise from an adaptive function: the need to keep problem representations simple enough to remain within the capacity of cognitive bounds (i.e., on working memory). Alternatively, decision makers need to find, or create, an alternative that is sufficiently superior to its competitors so that it can be defended from postdecisional challenges that occur to the decision maker or are posed by others (Svenson et al., 2009). Finally, according to theories of cognitive consistency, data interpretation errors may arise from an inherent need to avoid cognitive tension by forming coherent representations, where perceptions, beliefs, attitudes and feelings are all consonant with each other (Simon et al., 2004). Even when clinicians agree on the presence of certain clinical findings, wide variations have been found in the importance assigned to these findings in the course of interpreting their meaning. Data interpretation errors occur not only postdiagnosis but also while clinical data are being evaluated before a final diagnosis. The latter phenomenon is known as ‘predecisional information distortion’ and has been observed and measured in a variety of judgement tasks (e.g., consumer, legal, political, investment, risk, medical) and with different populations, both lay and expert (see review by DeKay, 2015). Predecisional information distortion involves changing the value of incoming information to support the hypothesis or preference that is currently leading. It thus treats reasoning as bidirectional, from the observed data to an emerging

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hypothesis and from that hypothesis to any new data. From this point of view, predecisional information distortion is incompatible with the Bayesian approach that relies on the independence of the observed data from the prior hypothesis. Distortion of information can occur either by bolstering information in relation to the leading hypothesis or by denigrating information in relation to a trailing hypothesis. Two studies by Nurek et al. have found a tendency towards denigration in physicians’ diagnostic judgements, i.e., undervaluing support for the trailing hypothesis, in comparison to unbiased evaluations of information by a control group (Nurek et al., 2014). Distortion is driven by the strength of belief in the initial diagnosis and, in turn, can maintain commitment to that diagnosis during the course of a diagnostic problem (Kostopoulou et al., 2012). Given that an initial hypothesis can bias judgement and lead to the wrong final diagnosis and decision (Kostopoulou et al., 2017b), we need to pay more attention to how physicians interpret information during the diagnostic process.

Errors in Probability Estimation Many errors in probability revision result from reasoning tendencies, known as cognitive heuristics, which rely on the most salient and easily accessible information. These simple heuristics provide good estimates in most contexts but may yield systematic biases in others. For example, people are prone to overestimate the frequency of vivid or easily recalled events and to underestimate the frequency of events that are either very ordinary or difficult to recall (Tversky and Kahneman, 1981). As a result of this ‘availability heuristic’, clinicians may pursue investigations for rare but memorable diseases or injuries and may overlook more common explanations for the patient's symptoms. Memorability can be influenced by factors unrelated to probability, for example, high emotion (a missed diagnosis that led to patient death), novelty (an unusual presentation or disease), personal experience (it happened to me, to my family, to a friend, to a colleague), recency (a patient I saw yesterday) or a good story (patient surviving against all odds). People also overestimate the frequency of events that fit their ideas of a prototypical or representative case (Tversky and

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Kahneman, 1974). When this ‘representativeness heuristic’ comes into play, the probability of a disease, given a finding (also known as the ‘positive predictive value’ of a finding), can be confused with the probability of a finding, given the disease (i.e., the ‘sensitivity’ of the finding). Small probabilities tend to be overestimated, and large probabilities tend to be underestimated (Tversky and Kahneman, 1981). Cumulative prospect theory (Tversky and Kahneman, 1992) and similar theories provide formal descriptions of how people distort probabilities in risky decision making. The distortions are exacerbated when the probabilities are vague and not precisely known (Einhorn and Hogarth, 1986). Recent work in the science of emotion has also highlighted ways in which task-engendered emotions influence the estimation of probabilities and many other kinds of judgements (Lerner et al., 2015) (Box 21.1).

Box 21.1

Some Common Biases in Estimating Probability ■ Overestimating probability of easily recalled events ■ Overestimating probability of events that fit a perceived pattern ■ Overestimating small probabilities ■ Underestimating large probabilities ■ Overconfidence in probability estimates

Errors in Probability Revision Conservatism In clinical case discussions, data are commonly presented sequentially. In this circumstance, people often fail to revise their diagnostic probabilities as much as they should, according to Bayes’ theorem. This ‘stickiness’ has been called conservatism and was one of the earliest cognitive biases identified (Edwards, 1968). A

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heuristic explanation of conservatism is that people revise their diagnostic opinion up or down from an initial anchor, which is either given in the problem or subjectively formed. Final opinions are sensitive to the anchor, and the adjustment up or down from this anchor is typically insufficient, so the final judgement is closer to the initial anchor than Bayes’ theorem would require (Tversky and Kahneman, 1974). The effect of conservatism is compounded when, in collecting data, there is a tendency to seek information that confirms the current hypothesis rather than data that facilitate efficient testing of competing hypotheses. This tendency has been called ‘pseudodiagnosticity’ (Kern and Doherty, 1982) or ‘confirmation bias’. Explanations, based on information-processing approaches to studying decision making, explain conservatism and confirmation bias in terms of how and in what order information is sampled from memory and the environment (Oppenheimer and Kelso, 2015).

Confounding Probability and Value of an Outcome It is difficult for everyday judgement to keep separate accounts of the probability of a particular disease and the benefits that accrue from detecting it. Probability revision errors that are systematically linked to the perceived cost of mistakes demonstrate the difficulties experienced in separating assessments of probability from preferences or values (Poses et al., 1985), a phenomenon also known as ‘value-induced bias’.

Base-Rate Neglect The basic principle of Bayesian inference is that a posterior probability is a function of two variables, the prior probability and the strength of the evidence. Some studies have found that, unless trained to use Bayes’ theorem and to recognize when it is appropriate, physicians are just as prone as anyone else to misusing or neglecting base rates in diagnostic inference (Elstein, 1988). Other studies, however, have failed to find evidence of base-rate neglect (Gill et al., 2005). In fact, in some clinical disciplines, such as general

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practice (family medicine), physicians are particularly sensitive to base-rate information (Sirota et al., 2017).

Order Effects Bayes’ theorem implies that, given identical information, clinicians should reach the same diagnostic opinion, regardless of the order in which information is presented. Order effects mean that final opinions are also affected by the order of presentation of information. Some studies have found primacy effects in diagnostic judgements (e.g., Nurek et al., 2014), and others have found recency effects (Bergus et al., 1995). In other words, the information presented early (or late) in a case is given more weight than information presented later (a primacy effect) (or earlier – a recency effect). Inconsistencies in the study results most likely stem from the different research methodologies and structure of the clinical cases employed. This, nevertheless, does not invalidate the general finding that order of information matters (Box 21.2).

Box 21.2

Some Common Biases in Revising Probabilities ■ Ignoring or overrelying on the initial probability ■ Inadequate adjustment of initial probability ■ Searching only for confirming evidence ■ Interpreting neutral evidence as confirming evidence ■ Confusing the seriousness of error (missing the disease) with the disease probability ■ Greater attention to evidence presented early or late in the process

Educational Implications What can be done to help learners acquire expertise in clinical reasoning? Particularly in light of the two-system theory of

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cognition, we endorse the multiple reasoning strategies position espoused by both Norman and Eva (2010) and seek to identify educational implications from both intuitive and analytical models in problem solving and decision making.

Problem Solving: Educational Implications Even if experts in nonproblematic situations do not routinely generate and test hypotheses and instead retrieve a solution (diagnosis) directly from their structured knowledge, they clearly do generate and evaluate alternatives when confronted with problematic situations. For novices, most situations will initially be problematic, and generating a small set of hypotheses is a useful procedural guideline. Because much expert hypothesis generation and testing are implicit, a model that calls it to the novice's attention will aid learning. The hypothetico-deductive model directs learners towards forming a conception of the problem and using this plan to guide the workup. This plan will include a set of competing diagnoses and the semantic relationships that facilitate separating between similar and different diagnostic candidates. This makes it possible to reduce unnecessary and expensive laboratory testing, a welcome emphasis in an era that stresses cost containment. Clinical experience is needed in contexts closely related to future practice, because transfer from one context to another is limited. In one way, this phenomenon reinforces a very traditional doctrine in medical education: Practical arts are learned by supervised practice and rehearsal supplemented by didactic instruction. In another way, it conflicts with traditional training, because the model implies that trainees will not generalize as much from one context (say, hospitalized patients) to another (say, ambulatory patients) as has traditionally been thought. For reasoners to generalize from specific exemplars to more abstract patterns, clinical experience must be reviewed and analyzed so that the correct general models and principles are abstracted from the experience. Well-designed educational experiences can facilitate the development of the desired cognitive structures. Given the emerging consensus about characteristics

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distinguishing experts from novices, an effective route to the goal would be extensive, focussed practice and feedback with a variety of problems (Eshach and Bitterman, 2003).

Decision Making: Educational Implications If expert clinicians are not consistent in their approach across cases, what can or should be taught to learners? In this section, we review some recent efforts to teach clinical decision making that have been strongly influenced by decision psychology principles and research results. Again, as dual-process theory has emerged as the dominant paradigm of judgement, medical educators have begun to wrestle with its implications for education (Pelaccia et al., 2011).

Evidence-Based Medicine EBM is particularly relevant for the diagnostic inference process discussed in this chapter because it is currently the most popular vehicle explicitly advocating a Bayesian approach to clinical evidence. Textbooks on EBM (e.g., Strauss et al., 2010) show how to use prevalence rates and likelihood ratios to calculate posterior probabilities of diagnostic alternatives (predictive value of a positive or negative test), and at least one recent study suggests that prevalence data may be readily available in the medical literature for inpatient adult medicine problems (Richardson et al., 2003). Formal statistical reasoning and decision analysis are likewise explained and advocated in an ever-growing number of works aimed at physicians (Kassirer and Kopelman, 1991; Lee, 2004; Mark, 2006; Sox et al., 1988). Decision theory, decision analysis and EBM seem to be on their way to becoming standard components of clinical education and training.

Decision Support Systems Computer programs that run on microcomputers or in conjunction with electronic health records and can provide decision support have been developed. The role of these programs in medical

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education and in future clinical practice is still to be determined, but they hold out hope for addressing both cognitive and systemic sources of diagnostic error (Graber et al., 2002; Kostopoulou et al., 2017a). A recent metareview of systematic reviews of computer decision support systems found four significant challenges that remain for such systems to become more useful to physicians: improvement in knowledge representation, ability to update the system's knowledge to match advances in medicine, stronger interoperability with electronic health records and better matching of decision support tools with clinicians’ cognitive workflow (Nurek et al., 2015).

Debiasing A number of researchers have proposed methods for debiasing judgements without resorting to formal methods of probability estimation and revision (Morewedge et al., 2015; Mumma and Wilson, 1995). General debiasing methods include educating decision makers about common biases, encouraging them to consider information that is likely to be underweighted or overlooked, e.g., consider alternative hypotheses, consider the opposite and so on, and making decision makers more accountable for their decisions. Evidence for the effectiveness of debiasing strategies for diagnostic reasoning is mixed (Graber, 2003); however, a recent systematic review by Lambe et al. (2016) found two types to be the most promising in improving diagnostic accuracy: asking clinicians explicitly to consider alternative diagnoses, and guided reflection, i.e., using a structured process to reflect and reason. Guided reflection tended to improve diagnostic judgement relative to using intuition or first impressions, particularly in complex cases.

Reflection Point 3 To reduce the chances of missing a diagnosis, ‘consider the opposite’: Think actively of other diagnostic alternatives. Consider case findings that do not support your current hypothesis or that also support other hypotheses.

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Embracing System 1 Not all educators and researchers agree that intuition must result in biased diagnosis or that it is inferior to analytical reasoning. Some have sought to demonstrate the conditions under which System 1 judgements can be better than System 2 judgements and under which conditions intuition can be further improved. In their review of heuristics in decision making, Gigerenzer and Gaissmeier (2011) identify fast-and-frugal trees as a valuable System 1 process that has received attention in diagnostic reasoning, both as a descriptive model of how physicians actually make diagnostic judgements and as a prescriptive approach to diagnosis that can outperform more complex, statistical clinical scoring rules, while being easier to apply. Research on fuzzy trace theory by Reyna et al. (see Blalock and Reyna, 2016) distinguishes between verbatim (System 2) and gist (System 1) encoding, retrieval and reasoning; research using the theory has demonstrated that reasoning from gist can lead to better decision making than reasoning from verbatim representations of the same problem (for a review, see Blalock and Reyna, 2016). Hogarth (2001) called attention to the importance of the learning environment (particularly the quality of feedback and cost of error) in improving System 1 judgements. ‘Kind’ learning environments provide timely, accurate, relevant and informative feedback, thus enabling quick and accurate learning, especially if the outcome of an error is damaging. Short-term weather forecasting is the archetypal ‘kind’ learning environment. In contrast, in ‘wicked’ learning environments, feedback is incomplete, irregular or delayed, and outcomes cannot easily be attributed to specific events, i.e., there are confounders that make learning difficult. When the error cost is low, decision makers may develop unwarranted confidence, not realizing that they have learned the wrong lessons or drawn the wrong conclusions. Unfortunately, most clinical environments have more wicked than kind learning features. Norman and Eva (2010) nevertheless reviewed studies in diagnostic reasoning in which both experts and novices performed better and made fewer errors when explicitly instructed to use their experience (rather than analytical reasoning) and pointed out that intuitive reasoning should not be suppressed, even were it possible.

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They concluded that medical education should encourage both System 1 and System 2 judgement.

Chapter Summary ■ Research on the clinical reasoning of physicians has examined differences between expert and novice clinicians, psychological processes in judgement and decision making, factors associated with nonnormative biases in judgement, improving instruction and training to enhance acquisition of good reasoning and the development, evaluation and implementation of decision support systems and guidelines. ■ Concerns about diagnostic error have become a motivating force in the study of clinical reasoning in medicine. Research in this area stands at the intersection of the interests of psychologists, medical sociologists, health policy planners, economists, patients and clinicians. ■ The prevailing view of two parallel and interacting cognitive systems, one fast and intuitive, the other slow and deliberative, has led to increased focus on how to study and improve each system and its interaction.

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Clinical Reasoning in Nursing Barbara J. Ritter, Michael J. Witte

CHAPTER AIMS The aims of this chapter are to: ■ discuss theoretical perspectives pertaining to clinical reasoning, ■ review studies relevant to understanding nurses’ clinical reasoning, ■ explore errors in diagnostic reasoning, implications and recommendations and ■ highlight educational strategies to promote clinical reasoning.

KEY WORDS Clinical reasoning Clinical guidelines Hypothetico-deductive model Intuition Pattern recognition

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Skilled know-how

ABBREVIATIONS/ACRONYMS CT Critical thinking EBP Evidence-based practice EHR Electronic health record H Hermeneutics IOM Institute of Medicine IPT Information Processing theory PBL Problem-based learning

Introduction Clinical reasoning represents the essence of nursing practice. It is intrinsic to all aspects of care provision and is critical to all forms of nursing education, practice and research. Knowledge about clinical reasoning is important for nursing education because education and teaching that are based on inappropriate or irrelevant models of reasoning can not only lead to wasted time and effort but also result in graduates who are ill-prepared to reason well in practice. Clinical reasoning is important for nursing practice. Patient care provision is becoming increasingly more complex and difficult. Nurses are assuming more responsibility with the emergence of nurse practitioners (NPs). There is, therefore, a need for sound reasoning skills to provide high-quality care with positive outcomes. It is also most important to avoid the costly, even deadly, mistakes that can occur from faulty reasoning and errors in decision making. An understanding of nurses’ clinical reasoning is an important part of nursing research. There is a need to develop and test theories of nurses’ cognitive processes and reasoning skills. Research is also needed to describe and explain the relationship between nurses’ reasoning and patient outcomes. The results of this research can help nurses assume greater responsibility in the healthcare delivery system as we develop and improve nursing practice.

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Definition of Clinical Reasoning The literature provides several definitions of nurses’ clinical reasoning. For example, Gordon et al. (1994) saw nurses’ reasoning as a form of clinical judgement that occurs in a series of stages: encountering the patient; gathering clinical information; formulating possible diagnostic hypotheses; searching for more information to confirm or reject these hypotheses; reaching a diagnostic decision; and determining actions. Ritter (1998) viewed clinical reasoning as a process involving inclusion of evidence to facilitate optimum patient outcomes. Using this logic, nurses’ clinical reasoning is important in four ways: 1. Understanding the significance of data 2. Identifying and diagnosing actual or potential patient problems 3. Making clinical decisions to assist in problem resolution 4. Achieving positive patient outcomes According to O'Neill et al. (2005), clinical decision making is a complex task geared towards the identification and management of patients’ health needs that requires a knowledgeable practitioner combined with reliable information and a supportive environment. From this perspective, with experience, nurses can develop a method of reasoning that provides them with an ‘intuitive grasp’ of the whole clinical situation, without having to rely on the step-bystep analytic approach of the formal nursing process. These authors advocated a nursing curriculum that would include activities that would foster students’ skills in intuitive judgement. Thus an understanding of nurses’ reasoning and decision making is essential and fundamental to providing care.

Theoretical Perspectives Several different theoretical perspectives have helped provide an understanding of nurses’ clinical reasoning: information processing, decision analysis and hermeneutics.

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Information Processing Theory Information processing theory (IPT) was first described by Newell and Simon (1972) in their seminal work examining how individuals with a great deal of experience in a specific area (domain expertise) reasoned during a problem-solving task. A fundamental premise of Information Processing theory is that human reasoning consists of a relationship between an information processing system (the human problem solver) and a task environment (the context in which problem solving occurs). A postulate of this theory is 1) that there are limits to the amount of information that one can process at any given time, and 2) that effective problem solving is the result of being able to adapt to these limitations. Miller's (1956) earlier classic work had demonstrated that an individual's working, short-term memory can hold only 7 +/− 2 symbols at a time. However, a critique of Miller's work is that it focussed on the ability to remember random, meaningless facts. Newell and Simon (1972) showed that the capacity of short-term memory could be greatly increased by ‘chunking’ simple units into familiar and more meaningful patterns. Individuals with a great deal of knowledge and meaningful experience in a particular domain can more easily chunk information pertaining to that domain and thus can make more efficient use of their short-term memory during reasoning. Meaningful experience is crucial. Another ‘memory bank’ identified by Newell and Simon (1972) was long-term memory, which has potentially infinite storage space for information. The theory proposes that information gained from knowledge and experience is stored throughout life in long-term memory and that it takes longer to access long-term memory information than the small amount of information temporarily stored in short-term memory. According to this theory, the information stored in long-term memory may need to be accessed by associating it with related information, which helps explain why experts reason so well within their own domain. Indeed, cognitive research has demonstrated that experts possess an organized body of domain-specific conceptual and procedural knowledge that can be easily accessed using reasoning strategies (heuristics) and specific reasoning processes that are gradually learned through academic learning and through clinical experience (Glaser and Chi,

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1988; Joseph and Patel, 1990).

Decision Analysis Theory Decision Analysis theory was introduced in medicine several decades ago as a method of solving difficult clinical problems. Decision Analysis theory methods include use of Bayes’ theorem, use of decision trees, sensitivity analysis and utility analysis. Using the Decision Analysis theory involves mathematical formulas, tabular techniques, nomograms and computer programs. These techniques use the clinical data to calculate the probability of certain diagnoses and outcomes. Several nursing studies have demonstrated the applicability of Decision Analysis theory to nurses’ decision making. In her classic study examining the relationship between the expected value (anticipated outcome) that nurses assign to each of their outcomes and their ranking of nursing actions, Grier (1976) demonstrated that nurses select actions that are consistent with their expected values, which seems to support the use of decision trees in some instances of nurses’ reasoning and decision making. Lipman and Deatrick (1997) found that NP students who used a decision tree made better decisions about diagnosis and treatment choices for both acute and chronic conditions. Lauri and Salantera (1995) studied decisionmaking models and the variables related to them. Findings were that the nature of nursing tasks and the context yielded the greatest difference in decision-making approach. Lewis (1997) found that conflict and ambiguity significantly increased task complexity. Therefore recommendations should consider task complexity during model design when developing decision models for use in nursing. Narayan et al. (2003) examined decision analysis as a tool to support an analytical pattern of reasoning; they found that decision analysis is especially valuable in difficult and complex situations when there are mutually exclusive options and there is time for deliberation. The reality is that in real-world practice there may not be time to work through a formal decision analysis. Formal decision analysis like this also assumes that the decision maker can gather all possible relevant information before making the final decision. This is in contrast to the use of heuristics and hermeneutics, which we consider next.

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Hermeneutics and Heuristics Hermeneutics is the art and study of interpretation. Hermeneutics should not be confused with heuristics or the use of cognitive shortcuts or rules of thumb. Heuristics can reduce the cognitive load and simplify the diagnostic reasoning process. Heuristics are often based on experience, patient characteristics and the context in which the patient presents. Good use of heuristics allows decisions to be made by gathering a limited amount of information, but this has to be information that is known to be relevant to the case. This is why past experience of similar cases matters. The past experience can help the nurse to judge what information might be most relevant. The intent of studies of nurses’ reasoning, using heuristics, is to understand how nurses interpret the clinical world, including their reasoning as they make decisions about patient care. This means we can use a hermeneutic approach in these studies. Benner et al. (1992) used a hermeneutic approach to study the development of expertise in critical care nursing practice. Their findings indicated that nurses at different levels of expertise ‘live in different clinical worlds, noticing and responding to different directives for action’ (Benner et al., 1992, p. 13). Findings from a later study by the same authors (Benner et al., 1996) indicate that this clinical world is shaped by experience that teaches nurses to make qualitative distinctions in practice. They also found that beginner nurses were more task oriented, and those with more experience focussed more on understanding their patients and their illness states. Many studies of nurses’ clinical reasoning have focussed on clinical judgement.

Clinical Judgement Studies Nurses’ clinical judgement represents a composite of traits that assists them in reasoning (Tanner, 1987). Benner et al. (1992), in their hermeneutic study, described characteristics of clinical judgement exhibited by critical care nurses with varying levels of practice experience when they reasoned about patient care. Characteristics of clinical judgement that were identified in the most experienced subjects included 1) the ability to recognize patterns in clinical situations that fit with patterns they had seen in other similar clinical cases, 2) a sense of urgency related to

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predicting what lies ahead, 3) the ability to concentrate simultaneously on multiple, complex patient cues and patient management therapies and 4) an aptitude for realistically assessing patient priorities and nursing responsibilities. The characteristics of clinical judgement identified by Tanner (1987) and Benner et al. (1992) assist in our understanding of nurses’ clinical reasoning by identifying and describing some of the cognitive traits or skills that nurses use during reasoning. Benner et al. (1996) and later Benner et al. (2011) in their subsequent work help further the theoretical understanding of nurses’ judgement that is needed to improve educators’ ability to teach their students to reason better and to provide nurses in practice with knowledge that will help them to solve problems and to make better decisions about patient care. In this later work, Benner et al. (2011) identified ‘nine aspects of being and thinking like a nurse’ (p. 9). They are as follows: 1. developing a sense of salience 2. situated learning and integrating knowledge acquisition and knowledge use 3. engaged reasoning-in-transition 4. skilled know-how 5. response-based practices 6. agency 7. perceptual acuity and interpersonal engagement with patients 8. integrating clinical and ethical reasoning 9. developing clinical imagination

Reflection Point 1 The nine aspects of being and thinking like a nurse all stem from a critical thinking approach, which involves analysis, evaluation and synthesis of content. This approach can be fostered with studentcentred learning activities, such as simulation, because they provide an opportunity for the theoretical memory to start to become ‘muscle memory’, or the movement from ‘knowing that’ to ‘knowing how’, according to Benner's 2015 Novice to Expert

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theory. Preceptorships with expert nurses, who exemplify the Bennerian qualities, are also powerful ways to expose novice nurses to role models who show what ‘thinking like a nurse’ means in the clinical setting.

Problem-Solving and Decision-Making Studies One of the primary objectives of clinical reasoning is to make decisions to resolve problems. Thus research into nurses’ problem solving and decision making provides understanding about the processes involved in their clinical reasoning. Problem-solving and decision-making studies can be regarded as a distinct body of research that is separate from Decision Analysis theory and hermeneutic studies. The assumption in these studies is that one of the primary objectives of clinical reasoning is straightforward resolution of problems. A number of researchers have investigated the complexity of nurses’ decision-making tasks from this perspective and have identified a range of reasoning strategies, including the hypothetico-deductive method, intuition and pattern recognition. Although there is frequently a focus on the healthcare professional making decisions alone, these studies sometimes do emphasize the importance of consultation with experienced colleagues, especially when still learning.

Intuition Studies Several investigators have proposed that intuition is an important part of nurses’ reasoning processes. A classic study that continues to guide nursing research on intuition was conducted by Pyles and Stern (1983) to explore the reasoning of a group of critical care nurses with varying levels of expertise. The investigators identified a ‘gut feeling’ experienced by the more seasoned nurse subjects, which they believed was just as important to nurses’ reasoning about patient cases as their formal knowledge. Subjects said they used these gut feelings to temper information from specific clinical cues; they also emphasized the importance of previous clinical experience in developing intuitive skills. Rew (1990) demonstrated the important role that intuition played in nurses’ reasoning and

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decision making. Subjects described their intuitive experiences as strong feelings or perceptions about their patients and about themselves and how they respond to their patients. These perceptions also involved anticipated outcomes that they sensed without going through an analytical reasoning process. Another perspective on intuition comes from Kahneman (2013), one of the pioneers of decision-making research, who proposed that intuition was nothing more or less than recognition, hence once again, the importance of experience.

Diagnostic Reasoning Studies Ritter (2000) studied the combination of two models (Information Processing and Hermeneutics) to explain diagnostic reasoning. Although previous research related to clinical reasoning used either Information Processing or Hermeneutical models (Fig. 22.1 and Box 22.1), it can be argued that neither model alone fully describes all components of diagnostic reasoning. The Ritter study systematically examined NPs’ diagnostic reasoning using both models.

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FIG. 22.1 Representation of the Information Processing and Hermeneutical model components.

Box 22.1

Hermeneutical Model Definition of Terms (Ritter, 2000) ■ Common-sense understanding is a common understanding in diverse situations of life in general. ■ Deliberative rationality is the ability to change one's interpretation of a situation by considering other alternatives. ■ Pattern recognition is the ability to recognize relationships among cues. ■ Sense of salience is understanding certain events to be more important than others. ■ Skilled know-how is independent of reliance on analytical thinking but rather involves processing numerous complex variables, simultaneously, in an unconscious, automatic,

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efficient manner knowing what to do, when to do it and how to do it to discern when particular findings might be relevant. ■ Similarity recognition is the ability to recognize similarities with past experiences even if the current experience differs from the previous experience. Findings suggest that both models operate among the 10 NPs who participated in this particular study (Ritter, 2000). The NPs used the Information Processing model 55% of the time and the Hermeneutical model 45% of the time. Gathering data is a key aspect of clinical reasoning. It involves using the senses to purposefully collect specific meaningful information about a patient so that diagnostic meaning can be assigned to the information. The Ritter (2000) study makes it clear that the process of gathering data in generating a hypothesis is essential as the hypothesis is a tentative state that may be altered, confirmed or negated. Thus forming a tentative diagnosis is important to guard against prematurely closing the diagnostic reasoning process before considering an alternative diagnosis. In the Ritter study, expert NPs demonstrated skilled know-how when they meticulously gathered, and carefully acquired, the appropriate data to formulate a diagnosis. That NPs use a combination of both models (Fig. 22.2) is the most significant finding of this study. Expert NPs’ diagnostic reasoning demonstrates an overlap and blending of each component. The two models of information processing and hermeneutics are quite different from the so-called dual-process theory of cognition.

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FIG. 22.2 Blended Information Processing and

Hermeneutical model.

The dual-process theory of cognition divides reasoning into System 1 and System 2 (Box 22.2). Pirret (2016) compared the diagnostic reasoning of 30 NPs and 16 resident physicians engaging with a complex case, using dual-process theory.

Box 22.2

Dual Processing Intuitive (System 1) and analytic (System 2) processes; the degree to which each is used is dependent on the clinical situation. ■ System 1 processes (commonly referred to as heuristics such as intuition, gut feelings, pattern recognition) are fast and are used automatically when clinicians are involved in familiar case presentations. Cognitive load is reduced, and the diagnostic reasoning process is simplified. This enables clinicians to reach a diagnosis without proceeding with the time-expensive process of exploring unlikely ‘differential’ diagnoses. ■ System 2 processes (commonly referred to as hypotheticodeductive reasoning) are slower, logical, methodical and deliberative.

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The Pirret (2016) study revealed that NPs incorporated more System 1 (intuitive) processes in general compared with residents. However, the diagnostic reasoning style, use of either more analytical or more nonanalytical reasoning, was not related to the preferred diagnostic reasoning abilities of the participants. Findings indicated that both NPs and resident physicians used System 2 (analytic) processes when required. New or difficult cases triggered System 2 thinking. However, regardless of which clinical reasoning processes are used, diagnostic errors can occur (Institute of Medicine, 2015).

Diagnostic Errors in Clinical Reasoning and Preventing In 2015, the Institute of Medicine (IOM) published a landmark study on diagnosis entitled ‘Improving Diagnosis in Health Care’. The report noted that many patients will at some time experience one or more diagnostic errors including delayed or inaccurate diagnoses. According to the report, far too little attention has been paid to diagnostic errors, and if not addressed the incidence of these errors will likely become worse. To improve the situation, the report made eight recommendations (p. 306): 1. Facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients and their families. 2. Enhance healthcare professional education and training in the diagnostic process. 3. Ensure health information technologies that support patients and healthcare professionals in the diagnostic process. 4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice. 5. Establish a work system and culture that support the diagnostic process and improvements in diagnostic performance. 6. Develop a reporting environment and medical liability system that facilitate improved diagnosis through learning from diagnostic errors and near misses. 7. Design a payment and care delivery environment that supports the diagnostic process.

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8. Provide dedicated funding for research on the diagnostic process and diagnostic errors.

Reflection Point 2 Clinical reasoning assignments that teach the students an analytical approach to the patient encounter provide a greater understanding of safe diagnostic processes. Informatics content that emphasizes a critical analysis of workflows enables students to identify inefficiencies and safety concerns in current care approaches. The informatics content also highlights how medical information systems, such as electronic health records (EHRs), are used to streamline communication of patient information and automate evidence-based practice and clinical decision tools. By understanding the way the EHR supports nursing, the student can maximize patient safety by correctly inputting patient data and utilizing the EHR's safety tools. The Institute of Medicine emphasized the importance of development of sound data tools to examine diagnostic reasoning and errors. These tools should, and could, be used to evaluate current practices in the diagnostic process. The data could also be used to compare diagnostic decisions with clinical outcomes. Important developments that aid this work are the rapid improvements in information technology such as the growth in digital records. Using these new developments, some progress has been made in addressing systems causes of diagnostic error. Information technology has improved clinicians’ ability to follow up on diagnostic tests in a timely fashion, which should reduce the incidence of delayed diagnoses. The development of an electronic workflow to standardize and improve communication among the team members could also reduce error. Del Fiol et al. (2008) and Zakim et al. (2008) claimed that diagnostic reasoning could be improved with electronic diagnostic decision support tools. For example, tools such as ‘info-buttons’ could be integrated into EHRs and provide direct links to relevant online clinical decision support (CDS) tools at the point of care. CDS tools encompass a variety of information resources, such as

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online medical textbooks, and clinical practice guidelines that can enhance decision making in the clinical workflow. The aim is to close the gap between research and practice by providing clinicians with electronically communicated clinical knowledge and patient information at critical points in the diagnosis and treatment process. Evidence-based practice (EBP) has become the cornerstone strategy for clinicians to translate research findings into clinical practice. By incorporating scientific evidence and EBP into decision making, CDS can improve patient treatment. This facilitates diagnostic accuracy and more rational care with better outcomes. Thus it is essential that nursing curricula include activities that foster students’ skills in diagnostic reasoning and are reflective of the realities encountered in actual practice, such as using modern technology on a regular basis.

Educational Focus on Clinical Reasoning As noted, nurses increasingly need well-developed reasoning skills to assist them in understanding and resolving the complex patient problems encountered in practice. Barrows and Pickell (1991, p. 3) remind us that ‘ambiguities and conflicting or inadequate information are the rule in medicine’. This is equally true in nursing, where dealing with complex patient problems with uncertain and unpredictable outcomes requires continual astute reasoning and accurate and efficient decision making. Thus the ability to think critically is essential. Lee et al. (2006) emphasize the importance of both cognitive and metacognitive skills, i.e., thinking about one's thinking, in clinical reasoning to promote the use of self-regulated learning and facilitate the development of critical thinking (CT) and reflective practice abilities. The cognitive skills that today's nursing students need to reason accurately and make decisions effectively in practice have prompted nurse educators to adjust their teaching methods. More creative teaching methods have been adopted that are designed to improve students’ reasoning skills and furnish them with a repertoire of creative approaches to care (Norman and Schmidt, 1993). Much of nursing education literature has begun to focus on ways to teach CT. Fonteyn and Flaig (1994) proposed using case studies to improve nursing students’ reasoning skills by teaching them to

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identify potential patient problems, suggest nursing actions and describe outcome variables that would allow them to evaluate the effectiveness of their actions. Case studies provide the advantage of allowing nurse educators to give frequent feedback in the safe environment of simulation and to provide reality-based learning (Manning et al., 1995; Neill et al., 1997; Ryan-Wenger and Lee, 1997). Lipman and Deatrick (1997) found that beginning NP students tended to formulate diagnoses too early in the datagathering phase, thus precluding consideration of all diagnostic options. When they used a case study approach incorporating algorithms to guide the decision-making process, students developed a broader focus, and diagnostic accuracy improved. To increase realism, case studies can be designed to provide information in chronological segments that more closely reflect real-life cases, in which clinical events and outcomes evolve over time (Fonteyn, 1991). Other methods that have been suggested by nurse educators to improve students’ CT skills include conferences, computer simulations, clinical logs, collaboration, decision analysis, discussion, e-mail dialogue, patient simulations, portfolios, reflection, role modelling, role playing and writing position papers (Baker, 1996; Fonteyn and Cahill, 1998; Kuiper and Pesut, 2004; O'Neill et al., 2005; Todd, 1998; Weis and Guyton-Simmons, 1998; Wong and Chung, 2002). O'Sullivan et al. (1997) indicated that teaching strategies that promote clinical reasoning are ones in which the educator designs classroom activities that explicitly engage the students in the activities of clinical reasoning. Paul and Heaslip (1995) advocated that students need to reason their way critically through nursing principles, concepts and theories frequently so that accurate application and transfer of knowledge occur in an integrated and intuitive way. Technological advances such as the Internet, with access to online video conferencing, journals, websites, interactive programs and distance learning, hold rich promise for promoting creative and effective teaching environments in addition to providing information sources (Fetterman, 1996). One learning activity that has proved popular for engaging students in clinical reasoning, with or without technology, is problem-based learning (PBL). PBL was first developed in medicine but has now been adopted

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by many nursing programs. PBL develops students’ ability to reflect frequently on their reasoning and decision making during patient care and leads to self-improvement through practice. Evidence exists that PBL significantly increases CT, clinical reasoning, problem solving and transfer of knowledge gained (Norman and Schmidt, 1993). Once students have developed their reasoning skills in this manner, they can then apply them while caring for real patients in the clinical setting. Fonteyn and Flaig (1994) suggested teaching nursing students to reason and plan care in the same manner as practicing nurses. In practice, nurses first identify (from data initially obtained in report form and confirmed by patient assessment) the most important patient problems on which to focus during their nursing shift. Information from the patient, the family and other members of the healthcare team should be included in a plan of care that will assist in resolving the problems identified. As the shift progresses, nurses regularly evaluate and refine their plan of care based on additional data obtained from further patient assessment, additional clinical data and information from all individuals involved in carrying out the plan of care. Durham et al. (2014) described teaching strategies to accelerate the development of student NP diagnostic reasoning. PBL was used to develop the hypothetico-deductive reasoning process in combination with assignments that fostered pattern recognition (a nonanalytical process), which effectively allowed NP students to experience the dual-process approach to diagnostic reasoning as used by NPs (see Case Study 22.1).

Case Study 22.1

PBL and Dual Process Reasoning Sonoma State University faculty applied the work of Durham et al. (2014) by using problem-based learning (PBL) cases that used the hypothetico-deductive and nonanalytical reasoning processes. Clinical case scenarios were presented to the students, and, with the assistance of the faculty, the students worked through each case. The faculty interaction during the case presentation also encouraged pattern recognition (a nonanalytical process) so

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reinforcing the dual-process model of diagnostic reasoning. Three cases were used that followed different paths. The clinical scenarios depicted various age groups and an increasing degree of complexity. The cases were presented as a chief complaint or symptom, and the students were asked to then interview the patient. The faculty encouraged the students to consider differential diagnoses early in the presentation of the case. The cases encouraged the students to consider all diagnoses, and, through the process, they were able to narrow down the possibilities and reach a most likely diagnosis. As the cases unfolded, further data gathering and clinical reasoning occurred, reinforcing the dual process of diagnostic reasoning. Students were positive about this approach to learning diagnostic reasoning. This process demonstrated a shift from the nursing model to the dualprocess approach to diagnostic reasoning used by other healthcare professionals. This is important as transitioning from a nurse, where the diagnosis is known, to that of an NP, whose job is to diagnose, requires the development of expert diagnostic skills. Videbeck (1997b) indicated that as well as being effectively taught, CT must be assessed in an appropriate manner. She pointed out that standardized paper-and-pencil tests are often selected as an evaluation measure because normative data are available and reliability has been established. However, none of the available instruments is specific to nursing, and there is no consistent relationship between scores on this type of test and CT. The use of faculty-developed instruments to assess student outcomes is strongly recommended. Course-specific measures, such as clinical performance criteria or written assignments, have the advantage of being specific to nursing practice. Videbeck (1997a) suggested that a model that integrates CT in all aspects of the program (definition, course objectives and evaluation) be used. Page et al. (1995) advocated the use of key feature problem (case scenario) examinations to assess clinical decision-making skills. In the future, educators must strive to devise additional methods to develop and improve nurses’ clinical reasoning. Further changes will be required in the structure and function of nursing curricula. Students need to learn to improve the ways in which they identify significant clinical data and determine the meaning of data in

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regard to the problems of particular patients. They also need to learn how to reason about patient problems in ways that facilitate decisions about problem resolution.

Practice The ultimate goal of both research and educational endeavours related to clinical reasoning in nursing is to improve nurses’ reasoning in practice and, ultimately, to achieve more positive patient outcomes. Nurses’ reasoning and interventions have a significant effect on patient outcomes (Fowler, 1994). We need to further explore the relationship between nurses’ reasoning and patient outcomes, especially if nurses continue to extend their roles and take on more responsibility for deciding what care patients need. A major difficulty in demonstrating the influence of nurses’ reasoning on patient outcomes is the complex nature of those outcomes. Outcomes span a broad range of effects, or presumed effects, that are influenced not only by nursing and other healthcare providers but by many other variables. These include time, environmental conditions, support systems and patient history. Therefore continued development of decision support systems and expert systems to assist nurses in practice to make better clinical decisions and prevent diagnostic errors remains important. Expert system development began in research laboratories in the mid-1970s and was first implemented in commercial and practical endeavours in the early 1980s (Frenzel, 1987). Fonteyn and Grobe (1994) suggested that an expert system could be designed to represent the knowledge and reasoning processes of experienced nurses and could then be used to assist less experienced nurses to improve their reasoning skills and strategies. ‘Illiad’ is one such expert system case-based teaching program, which has been shown by Lange et al. (1997) to be effective in improving NP students’ diagnostic abilities. Bowles (1997) claimed that expert system shells (computer systems that emulate the decision-making ability of a human expert) could be used in nursing. However, the nature of artificial intelligence and expert systems has changed in recent years with a move to machine learning. This change is showing great promise. Machine learning makes use of so-called ‘big data’. There is a need to develop data sets that can link nursing decisions

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with patients’ outcomes if these newer computer systems are to help nurses. More recently, Feldman et al. (2012) showed that a diagnostic decision support tool has a significant beneficial effect on the quality of first-year medicine residents’ differential diagnoses and management plans. Recommendations were for further research to determine whether computer-based decision support tools with clinical workflows would facilitate improved diagnosis and more appropriate management at the point of care in healthcare settings.

Future Directions in Practice Related to Nurses’ Clinical Reasoning The relationship between nurses’ reasoning and patient outcomes should receive greater attention in future research to demonstrate the important role that nurses play in healthcare delivery. There will be an increasing need to develop meaningful data sets related to patient outcomes. These data sets should allow us to record the actions that nurses commonly choose after reasoning about specific patient problems and relate these actions to intervention outcomes. Before the development of these data sets, the indicators of patient outcome that are related to nurses’ reasoning and decision making need to be identified and described in a manner that facilitates their measurement. Computerized support systems will play an everincreasing role in assisting nurses to reason, make decisions about appropriate nursing actions and evaluate their effect on patient outcome. Further studies are needed to evaluate the effect of these interventions on diagnostic error rates.

Chapter Summary In this chapter:

■ Multiple theories have been discussed, including information processing, decision analysis and hermeneutics. These each contribute to how we can understand nurses’ clinical reasoning, clinical 545

judgement, problem solving and decision making and diagnostic reasoning. ■ Research into the clinical reasoning of nurses has been explored. This research has often produced useful insights, but there is a need to build on this research. ■ Ways to decrease diagnostic errors and improve clinical reasoning were explained. Recommendations proposed emphasize collaboration, communication, teamwork and decision support modalities and teaching strategies that promote CT and clinical reasoning. Reflection Point 3 Multiple theoretical strategies can be employed such as simulations, role modelling, case studies and other in our curriculums to enhance clinical reasoning. Of these methods, PBL has been shown to facilitate application of acquired principles in the clinical arena. PBL combines problem-solving skills with didactic content within a clinical context that is organized to mimic the analytic reasoning process in clinical practice. Working through rich PBL cases helps students remember key information and see its application to real life. Looking to the future, further research on ways to promote CT and clinical reasoning is of importance.

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23

Clinical Reasoning in Physiotherapy Mark Jones, Ian Edwards, Gail M. Jensen

CHAPTER AIMS The aims of this chapter are to: ▪ discuss three important reasons why physiotherapists need to study and practice clinical reasoning, ▪ discuss three frameworks that can provide context and focus to the learning and practice of clinical reasoning in physiotherapy and ▪ discuss factors beyond cognitive processes that influence proficiency in clinical reasoning.

KEY WORDS Evidence-informed practice Human judgement Errors in clinical reasoning Fast and slow reasoning

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Biopsychosocial framework Clinical reasoning strategies Hypothesis categories Factors influencing clinical reasoning

ABBREVIATIONS/ACRONYMS CNS Central nervous system ICF International Classification of Functioning, Disability and Health

Introduction Two significant challenges to skilled clinical reasoning in physiotherapy practice since the last edition of this book have been the continued growth of research evidence clinicians are expected to know and use and the increased understanding in pain science; the latter has driven an increased emphasis on psychosocial assessment, pain education and cognitive-behavioural management (especially in, but not limited to, musculoskeletal practice). The political pressure to be ‘research/evidence-based’ is greater than ever. This is despite the plethora of systematic reviews now available concluding, more often than not, that there is insufficient high-level research to judge what managements are best. Pain science and chronic pain/disability research convincingly highlight the importance for physiotherapists to develop particular skills. These skills include psychosocial assessment for prediction of return to work and chronicity and psychologically informed management for already established ‘chronic’ presentations. Although formal education, in physiotherapy psychosocial assessment and management, is increasing, it is still arguably not well developed and often not well integrated into the clinical practice components of the curriculum. Psychosocial assessment and management, and similarly the clinical reasoning required for making judgements regarding psychosocial factor contribution to a patient's disability, are less formalized, less familiar and often seen as not as important as developing skills in physical assessment and management. Physiotherapy ‘hands-on’ procedural skills may be

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under threat from those who promote education (e.g., in pain management) as a replacement to established physical therapies rather than something that needs to be integrated with those same therapies (Edwards and Jones, 2013; Jull and Moore, 2012). Skilled clinical reasoning is more important than ever because of the external pressures for greater efficiency and quality patient outcomes. Within this context, research evidence should be seen as an important source of information and not a prescription.

Why Do Physiotherapists Need to Study and Practice Clinical Reasoning? Research Evidence Only Provides a Guide, Not a Prescription, to Practice Despite its exponential growth over recent decades, our current body of research is far from conclusive in terms of sufficiently informing clinical decisions. Research is often insufficient to adequately guide therapists in their recognition and management of the multitude of patient problems we face (Jones et al., 2006; Mosely et al., 2014; Villas Boas et al., 2013). Further, the validity and status of what knowledge is actually derived from different populations within physiotherapy are often uncertain (Kerry et al., 2013). Common limitations with physiotherapy effectiveness studies include high dropout rates or loss to follow-up, lack of blinding (patient, therapist, measurer), lack of random and concealed allocation to treatment arms, lack of adequate identification of population subgroups, artificial isolation of treatment interventions in determining their effect and lack of evidence of sustainable outcomes. As such, practicing clinicians face the daunting challenge of maintaining best practice based on best evidence when the evidence is still largely not available or is incomplete. Even when primary research studies (or systematic reviews) testing therapeutic interventions for the condition of interest are available, numerous issues must be considered for the clinician to have confidence in the

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applicability of the findings. These issues include whether or not their patient matches the population studied (often made difficult by lack of homogeneity of subjects and insufficient consideration of psychosocial variables) and whether the intervention tested can be replicated. Very few studies provide sufficient detail and justification of the assessments and treatments to enable clinicians to replicate the assessments and management (educatively, behaviourally and humanistically) with confidence. The details needed include what precisely was done, including details of positions, dosage, sequence and progression; who treated the patients, including level of procedural competence; and what was the therapeutic environment, including associated explanations, instructions, verbal cues and advice. Application of this evidence to practice requires skilled clinical reasoning and judgement.

Human Judgement Is Prone to Error Although inadequate knowledge understandably underpins errors of judgement, it is disconcerting to know that many errors in health- and nonhealth-related human judgement can be traced to the tendency for human bias (e.g., Hogarth, 2005; Kahneman et al., 1982; Lehrer, 2009; Schwartz and Elstein, 2008). Some examples, easily recognizable in clinical practice, include those in Box 23.1.

Box 23.1

Biases in Human Judgement ▪ The ‘priming’ influence of prior information (e.g., diagnosis provided in a referral, imaging findings, influence of a recent publication or course) ▪ ‘Confirmation bias’ or the tendency to attend to and collect data that confirm existing hypotheses ▪ ‘Memory bias’ of a spectacular successful outcome ▪ ‘Overestimation of representativeness’, as with the probability of a diagnosis given a finding being confused with the probability of a finding given a diagnosis (e.g., having a diagnosis of TB means there is a high probability you have a

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cough, but having a cough does not mean you have a high probability of having TB) ▪ ‘Conservatism or stickiness’, where initial impressions and hypotheses are not revised in the face of subsequent nonsupporting information ▪ ‘Associative coherence’, where we understandably attempt to provide coherent explanations of how signs and symptoms are associated TB, Tuberculosis

Fast and Slow Reasoning in Physiotherapy Practice Although thinking in clinical practice varies across therapists, three broad distinctions can be made. There are those who simply follow diagnostic/guideline prescriptions and uncritically administer treatment protocols as a technician (i.e., no clinical reasoning adaptation to the individual patient). There are those who make their own clinical judgements based on dominant features in a clinical presentation and use routine, habitual management strategies (i.e., ‘fast’ reasoning or forward reasoning). Finally, there are those who more holistically, reflectively and analytically examine and reason to understand their patients’ full pain or disability experiences. The third group does this to adapt research/guideline evidence to collaboratively manage a patient's unique physical, psychosocial and environmental requirements (i.e., ‘slow’ reasoning or backwards reasoning). In reality, in addition to being holistic and collaborative in their reasoning (see Chapter 15), expert physiotherapists use a combination of fast and slow reasoning as required by the complexity and familiarity of the patient's unique clinical presentation and context. In his seminal text Thinking, Fast and Slow, Daniel Kahneman (2011) describes fast thinking as automatic, effortless first impressions and intuition (e.g., pattern recognition) and slow thinking as analytical deliberations requiring more attention, time and effort. Although shortcuts in thinking such as pattern recognition can be effective when working with very familiar presentations where little

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problem solving is required, errors are likely to occur if relied on in less familiar, more complex presentations. Consider the scenario where a patient reports midthoracic pain consistently provoked after sitting slouched to eat lunch. Working on the premise that sustained flexion can strain spinal tissues leading to nociception, the physiotherapist deduces ‘I've seen this before, the patient's midthoracic pain is caused by nociception associated with slouched sitting’ and proceeds to postural assessment and advice. Although this inductive fast reasoning judgement certainly represents one plausible explanation to explore further, this patient actually had gallbladder disease with referred thoracic pain related to eating fatty foods at lunch, not slouched posture. Even when you consider patients with easily diagnosed problems and well-established management guidelines, their personal circumstances, goals and the extent of relevant impairments will be unique, requiring analysis and collaborative decisions beyond fast reasoning alone. The greater the coherence of our fast reasoning impressions, the more likely we are to jump to conclusions without further slow reasoning analysis. Unfortunately, humans are prone to find and accept coherence on the basis of limited information. Kahneman (2011, p. 86) has characterized this trait, associated with many of our biases, as ‘What You See Is All There Is’. There is an assumption or acceptance that the information at hand is all that is available. You build a story (explanation) from the information you have, and if it is a good, coherent story, you believe it. Paradoxically, coherent stories are easier to construct when there is less information to make sense of. Although overreliance on fast reasoning can clearly lead to errors, interestingly, research has demonstrated experts working with familiar problems function largely on pattern recognition (e.g., Boshuizen and Schmidt, 2008; Jensen et al., 2007; Kaufman et al., 2008; Schwartz and Elstein, 2008). Overanalysis also leads to errors in judgement (Lehrer, 2009; Schwartz and Elstein, 2008). The existence of our fast reasoning is obvious when you consider the large number of first-impression, fast-thinking judgements that lead up to, and inform, our understanding of the patient and his or her problems. These judgements include quick recognition of when a patient's telling of his or her story requires clarification; patient discomfort and emotions; observed postural,

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movement and control impairments; when a hands-on intervention requires mid-treatment adjustment and so on. Openness to reflect on practice and recognition when an existing approach is inadequate are part of what has been described as ‘adaptive expertise’ (Cutrer et al., 2017). Successfully working with patients with complex presentations that fall outside what are typically uni-dimensional clinical guidelines requires a balance in fast and slow reasoning. There is a need to reframe the problem and combine this with an ability to adapt, explore and invent creative solutions. Clinicians have to be able to integrate and manage uncertainty as part of their clinical reasoning process (Cooke and Lemay, 2017). This requires critical thinking skills, as discussed later, but also creative or lateral thinking (de Bono, 2014). de Bono characterizes vertical thinking as logical, sequential, predictable thinking where the thinker aims to systematically make sense of all information. In contrast, lateral thinking involves restructuring and escaping from old patterns, looking at things in different ways and avoiding premature conclusions. Being able to reframe a problem and consider different perspectives requires first being able to recognize your own perspective or approach. For example, a student could be encouraged to conduct a review of patient progress and his or her reasoning through the problem. The student is explicitly asked to identify his or her dominant interpretation of the patient's diagnosis (e.g., pathology versus impairment, physical versus psychosocial) and the dominant approach he or she has been taking in management to date (e.g., passive or dynamic bias, bias to treating source versus contributing factors, bias to physical impairments versus psychosocial factors). It is difficult to think laterally/creatively if you cannot first recognize how you have been thinking and approaching the problem thus far. Once this is recognized, the student can then be encouraged to think more laterally about alternative interpretations of the patient's presentation and alternative management approaches.

Reflection Point 1 Can you identify any of the common errors of reasoning present in your practice? What strategies do you use to minimize errors?

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Three Frameworks to Situate Clinical Reasoning in Physiotherapy Clinical reasoning is increasingly acknowledged as important in clinically focussed publications, conference presentations and professional association practice competencies. However, outside of scholarly works that focus on clinical reasoning (e.g., Edwards et al., 2004a; Jensen et al., 2007, and this Clinical Reasoning in the Health Professions text), it is often referred to as a broad construct without reference to the scope of clinical judgements that should be considered or the dynamics of the reasoning process. Reference to clinical reasoning is usually focussed on pathoanatomical diagnosis and management despite significant limitations in the associations between pathology, symptoms and disability. Three frameworks that can provide context and focus to the learning and practice of clinical reasoning in physiotherapy are the ‘biopsychosocial’ framework (Engel, 1977), ‘clinical reasoning strategies’ and ‘hypothesis categories’.

Clinical Reasoning in a Biopsychosocial Framework Physiotherapists must consider all factors potentially contributing to a person's health, whether working with patients having musculoskeletal/sports, neurological, oncological or cardiorespiratory problems from infants through to old age or when working in health promotion/injury prevention. Although physiotherapists are often perceived as having a focus on the ‘physical’, a contemporary biopsychosocial understanding of health and disability (Borrell-Carrió et al., 2004; Epstein and Borrell-Carrió, 2005; Imrie, 2004) requires full consideration of environmental and psychosocial factors that may influence physical health, within the scope and limits of the therapists’ education. This requires a holistic philosophy of health and disability, assessment and management knowledge (including referral pathways) and skills to address any potential contributing factors. In addition, clinical reasoning proficiency is required to recognize whether these contributing factors are relevant to the individual patient to make appropriate

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clinical judgements that will contribute to the patient's optimal health care. The biopsychosocial perspective recognizes that disability is the result of the cumulative effects of the biological health condition (disease, illness, pathology, disorder), external environmental influences (e.g., physical, social, economic, political) and internal personal influences (e.g., age, gender, education, beliefs, culture, coping style, self-efficacy). The World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model (Fig. 23.1) provides an excellent overarching biopsychosocial framework that illustrates the scope of knowledge that clinical reasoning physiotherapists need to be competent to holistically understand and manage their patients.

FIG. 23.1 Adaptation of World Health Organization

International Classification of Functioning, Disability and Health Framework. (From World Health Organization, 2001. International Classification of Functioning, Disability and Health. World Health Organization, Geneva, with permission.)

The boxes across the middle of the diagram depict the relationship between a patient's body function and impairments, his or her capabilities to do activities and his or her participation in life situations (e.g., work, family, sport, leisure). Bidirectional arrows reflect the reciprocal relationships whereby different factors

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have the potential to influence each other (Borrell-Carrió et al., 2004; Duncan, 2000; Pincus, 2004). Formerly, functional restrictions, physical impairments and pain would have been conceptualized as the end result of a specific injury/pathology or syndrome, but the reciprocal arrows highlight that these also can be associated with, and even maintained by, environmental and personal influences. A holistic understanding of a patient's clinical presentation therefore necessitates attention and analysis of his or her physical health, environmental and personal factors. The ICF model provides an excellent contextualization of the scope of knowledge and clinical reasoning required in physiotherapy practice. A framework of ‘clinical reasoning strategies’ provides further assistance to understanding and learning clinical reasoning.

Focus of Our Clinical Reasoning: Clinical Reasoning Strategies As previously mentioned, it is common for clinical reasoning presentations and discussions to focus on diagnosis alone, with diagnosis limited to categorizing the type of problem, injury or pathology. Pathology is important because red flags, signs and symptoms suggestive of undiagnosed, possibly sinister health problems, require further investigation. However, clinical reasoning that overfocusses on pathology at the expense of other factors, such as the psychosocial, physical impairment and environmental, is at risk of incomplete understanding of a patient's issues. Pathology can be asymptomatic, and symptoms can exist without detectable pathology. Symptomatic pathology will have a continuum of presentations, relating to stage and severity of pathology and interactions from other health comorbidities and psychosocial and environmental contributing factors. Reasoning about diagnosis/pathology represents only a portion of the reasoning that actually occurs in clinical practice. Physiotherapy diagnostic reasoning should, arguably, be broader than the categorization focus of our medical colleagues and include physiotherapy-specific features important to our subsequent management. Research and theory across a range of health professions (e.g., physiotherapy, medicine, nursing, occupational therapy) have identified a range of clinical reasoning foci (Edwards et al., 2004a). We suggest the

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following clinical reasoning strategies capture the scope of reasoning necessary to apply the ICF biopsychosocial model to physiotherapy practice (Box 23.2).

Box 23.2

Applying the International Classification of Functioning, Disability and Health Biopsychosocial Model to Physiotherapy Diagnostic reasoning: Reasoning underpinning the formation of a diagnosis related to functional limitation(s) and associated physical and movement impairments with consideration of pain type, potential sources of symptoms, pathology and the broad scope of potential contributing factors. Narrative (or psychosocially focussed) reasoning: Reasoning associated with understanding patients’ pain, illness and/or disability experiences. This incorporates their personal perspectives on their experiences including their understanding of their problem(s) and the meanings they hold, their expectations regarding management, associated cognitions and emotions, ability to cope and the effects these personal perspectives have on their clinical presentation, particularly whether they are facilitating or obstructing their recovery. Reasoning about procedure: Reasoning underpinning the selection, implementation and progression of treatment procedures. Although clinical guidelines provide broad direction, typically focussing only on diagnostic categorization, practicing therapists need to adaptively reason how best to apply those guidelines to patients’ individual presentations and goals. Progression of treatment is mostly then guided by judicious outcome reassessment that attends to both impairment and function/disabilityrelated outcomes. Interactive reasoning: Reasoning guiding the purposeful

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establishment and ongoing management of therapist–patient rapport. Collaborative reasoning: The shared decision making between patient and therapist (and others) as a therapeutic alliance in the interpretation of examination findings, setting of goals and priorities and implementation and progression of treatment (see Edwards et al., 2004b, and Trede, Higgs, 2008, for further detail). Reasoning about teaching: Reasoning associated with the planning, execution and evaluation of individualized and context-sensitive teaching of patients, including education for conceptual understanding (e.g., medical and physiotherapy diagnosis, pain, management options), education for physical performance (e.g., rehabilitative exercises) and education for behavioural change. Predictive reasoning: Reasoning utilized in judgements regarding effects of specific interventions and overall prognosis. Although prognostic judgements regarding whether physiotherapy can help and expected time frames are not precise, thorough consideration of biological, environmental and personal factors that recognizes both facilitators and barriers (i.e., positives and negatives in a patient's presentation) and what is and is not modifiable will assist this reasoning strategy. Ethical reasoning: Reasoning underpinning the recognition and resolution of ethical dilemmas that impinge upon the patient's ability to make decisions concerning his or her health and upon the conduct of treatment and its desired goals (see Chapter 16 for further detail). Expert physiotherapists have been shown to attend to these various reasoning strategies and also move dialectically in their reasoning between a biological and psychosocial focus in a fluid and seemingly effortless manner (Edwards et al., 2004a). For example, a diagnostic test may elicit a patient response that is more reflective of his or her fear of movement rather than any underlying pathology. Even though the diagnostic test may be associated with good sensitivity, specificity and likelihood ratios, the expert clinician will recognize the need to dialectically switch from

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biological to biopsychosocial thinking. Although the clinical reasoning strategies provide a framework to assist students and practicing physiotherapists, to recognize the different foci of reasoning required in biopsychosocial practice, it is also helpful to recognize that different categories of clinical judgements are required across these different reasoning strategies.

Reflection Point 2 Do you explicitly assess patients’ psychosocial status? If so, what do you assess, how do you assess it and how do you judge a psychosocial feature is contributing to a patient's presentation?

Categories of Clinical Judgements Required: Hypothesis Categories One would hope that all physiotherapists know the purpose of every question they ask their patients and every physical assessment they perform. That is, what do you want to find out, and what clinical judgements will that information inform? It is not appropriate to stipulate a definitive list of clinical judgements all physiotherapists must consider as this has not been established and would only stifle the independent and creative thinking important to the evolution of our profession. However, active reflection on all, and any, information about a patient helps clinicians in a number of ways. Reflection can help clinicians understand the purpose of the questions they ask and the assessments they do. Reflection can encourage clinicians to think more broadly beyond the immediate diagnosis. Finally, reflection can encourage the creation of frameworks to organize clinical knowledge in ways that allow good decisions to be made. A minimum list of categories of judgements was initially proposed by Jones (1987). This has continued to evolve to its current format (Box 23.3).

Box 23.3

Hypothesis Categories Framework 564

▪ Activity and Participation capability and restriction ▪ Activity: functional abilities and restrictions (e.g., walking, lifting, sitting) that are volunteered and further screened for. To gain a complete picture, it is important that the clinician identifies those activities the patient is capable of alongside those that are restricted. ▪ Participation: abilities and restrictions to participate in life situations (e.g., work, recreation/sport, family), including modified participation (e.g., modified work duties). ▪ Patient's perspectives on his or her experiences (i.e., psychosocial status) incorporating, for example: ▪ Understanding of his or her problem (including attributions about the cause, beliefs about diagnosis and pain and associated cognitions) ▪ Response to stressors in his or her life and any relationship these have with his or her clinical presentation ▪ Effects the problem and any stressors appear to have on his or her thoughts, feelings, coping, motivation and self-efficacy to participate in management ▪ Goals and expectations for management ▪ In the ‘Clinical Reasoning Strategies’ framework presented earlier, hypotheses regarding patient perspectives fit within ‘Narrative Reasoning’ focussed on understanding patients’ pain, illness and/or disability experiences. ▪ Pain type (i.e., ‘mechanisms’) ▪ Nociceptive pain (with and without inflammation): Nociceptive pain is protective and represents the sensation associated with the detection of potentially tissue-damaging noxious stimuli. Nociceptive inflammatory pain occurs with tissue damage and/or immune cell activation in the case of systemic inflammation, facilitating repair by causing pain hypersensitivity until healing occurs (Wolf, 2010). ▪ Neuropathic pain: pain arising as a direct consequence of a lesion or disease affecting the somatosensory system further differentiated into peripheral or central

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neuropathic pain depending on the anatomical location of the lesion (Jensen et al., 2011; Trede et al., 2008). ▪ Maladaptive central nervous system (CNS) sensitization: dysfunctional pain operationally defined as ‘an amplification of neural signalling within the central nervous system that elicits pain hypersensitivity’ (Wolf, 2010, p. s5) (see also Nijs et al., 2014; Wolf, 2011). ▪ Sources of symptoms: specific tissues, structures, body regions and body systems hypothesized as responsible for the presenting symptoms without specific reference to pathology. ▪ Pathology: structural and functional changes in the body caused by disease or trauma hypothesized to be associated with presenting symptoms and/or disability. ▪ Impairments in body function or structure: any loss or abnormality of psychological, physiological or anatomical structure or function (World Health Organization, 2001). ▪ Contributing factors to the development and maintenance of the problem: predisposing or associated factors involved in the development or maintenance of the patient's problem(s). Both intrinsic and extrinsic factors should be considered, including environmental, psychosocial, behavioural, physical/biomechanical and hereditary. ▪ Precautions and contraindications to physical examination and treatment: medical (e.g., comorbidities), environmental, psychosocial, behavioural and physical factors and ‘Red Flags’ (signs and symptoms that may indicate the presence of more serious pathology and systemic or viscerogenic pathology/disease) identified that inform: ▪ whether a physical examination should be carried out at all (versus immediate referral for further medical consultation/investigation) and, if so, the extent of examination that can be safely performed that will minimize the risk for aggravating the patient's symptoms/condition ▪ whether specific safety tests are indicated (e.g., cervical arterial dysfunction testing, neurological examination,

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blood pressure/heart rate, balance assessment, instability tests) ▪ whether any treatment should be undertaken (versus referral for further consultation/investigation) ▪ the appropriate dose/strength of any physical interventions planned. ▪ Management/treatment selection and progression: 1) overall health management of the patient, including consultation and referral to other healthcare professionals, health promotion interventions (e.g., fitness assessment and management) and patient advocacy as required (e.g., with insurers or employers) and 2) specific therapeutic interventions (educational and physical) carried out during an appointment and the underlying reasoning required to determine which impairments to address, which to address first, the strategy/procedure and dosage to use, the outcome measures to reassess and the self-management appropriate for optimizing change (in understanding, impairment, activity and participation). Progression of treatment informed by outcome reassessment has the same considerations. ▪ Prognosis: the therapist's judgement regarding his or her ability to help the patient and an estimate of how long this will take. Broadly a patient's prognosis is determined by the nature and extent of the problem(s) and the patient's ability and willingness to make the necessary changes (e.g., lifestyle, psychosocial contributing factors, physical contributing factors) to facilitate recovery or improved quality of life. Clues will be available throughout the subjective and physical examination and the ongoing management. There is now plentiful research evidence about the focus of clinical reasoning, including reasoning across and within these different categories (e.g., Barlow, 2012; Doody and McAteer, 2002; Edwards et al., 2004a; Jensen et al., 2007; Rivett and Higgs, 1997; Smart and Doody, 2006). This research, combined with reflective discourse from experienced clinicians and clinical educators, broadly supports the relevance and use of a hypothesis categories framework. Nevertheless, physiotherapists should not use these specific hypothesis categories uncritically. Whatever categories of

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judgements are adopted should continually be reviewed to ensure they reflect contemporary health care and clinical practice. Clinicians’ abilities to engage in ongoing self-assessment through reflection and self-monitoring are an essential lifelong skill (Schumacher et al., 2013). As physiotherapists (or students) follow their structured examination (i.e., review of records, patient interview, physical assessment depending on work setting) appropriate for each area of practice (e.g., musculoskeletal, clinical neuroscience, cardiorespiratory, paediatrics), they should recognize patient cues that in turn should elicit hypotheses in one or more categories. That is, clinical reasoning across the different hypothesis categories occurs simultaneously and with varying emphasis depending on the context and nature of the clinical situation and problems encountered. There are many different types of clinical patterns, including patterns within all hypothesis categories (Box 23.4).

Box 23.4

Different Types of Clinical Patterns ▪ Epidemiology of different health conditions ▪ Diagnostic and clinical syndromes (physiological processes, activity and participation restrictions, associated sources of symptoms, associated symptomatic pathologies) ▪ Patterns of ‘processes’ (e.g., degenerative, inflammatory, ischaemic, tissue strain) ▪ Patterns of activity and participation restrictions, symptoms and physical impairments common to different diagnostic and clinical syndromes (e.g., spinal stenosis, functional instability, chronic obstructive pulmonary disease [COPD], different strokes) ▪ Patterns of sources of symptoms (spinal posterior intervertebral joint, vascular, respiratory) ▪ Patterns of symptomatic pathology (tendinopathy, pulmonary embolus, vascular aneurysm) ▪ Factors predisposing or contributing to patients’ health

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conditions, physical impairments activity and participation restrictions ▪ Patterns of predisposing physical and environmental risk factors to musculoskeletal and sports-related problems (e.g., mobility, control/strength, sport training and equipment), cardiovascular disease (e.g., diet, weight, blood pressure, stress, smoking), chronic disability (e.g., socioeconomic status, inactivity, failure to return to work, beliefs about pain) ▪ Patterns of common environmental, social, cultural and personal contributing factors facilitating or restricting people's activity and participation ▪ Patterns of medical conditions, medications, symptoms and signs that signal the need for precautions to physical examination and treatment and/or referral for further medical consultation ▪ Patterns of management strategies for different diagnostic and clinical health conditions ▪ Patterns of factors suggesting poor to good prognosis (e.g., pathology/illness, impairments, environmental and personal factors) As specific hypotheses are considered, informed by knowledge of clinical patterns, tentative judgements should be ‘tested’ for the remaining features of the pattern through further patient inquiry, physical tests and ultimately with the physiotherapy intervention. Thinking of interpretations of patient information as hypotheses discourages premature conclusions and promotes synthesis of the full clinical story and physical assessment. Patient information typically has implications for several different hypothesis categories. Consider the following case study (Case Study 23.1).

Case Study 23.1

Patient Information and Clinical Reasoning A 72-year-old man is asked what aggravates his back and bilateral

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leg pains. His response is: ‘Walking. I'm afraid to even try anymore. Even short walks make the back and legs worse, and then I have to sit down to ease it off. Sitting is good, but I can't sit all day! I can't even help out around the house anymore or get over to see the grandchildren. I'm really worried it might be something serious’. The following preliminary interpretations (hypotheses) can be made: ▪ Activity restriction: walking ▪ Activity capability: sitting ▪ Participation restrictions: helping around house and seeing grandchildren ▪ Patient perspectives: afraid to try walking, worried it may be serious ▪ Pain type: consistent mechanical pattern – nociceptive? neuropathic? ▪ Sources of symptoms: lumbar joints and neural (peripheral? central?) implicated ▪ Pathology/syndrome: vascular claudication, stenosis (neuropathic claudication)? ▪ Contributing factors: age ▪ Precautions: age, easily aggravated, bilateral leg pain, patient's fears/worry ▪ Prognosis: (negatives) age, extent of symptoms and disability, neuropathic features, potential for patient's perspectives to be a barrier; (positives) specific easing factor The reasoning regarding each of these hypothesis categories would then continue to evolve throughout the ongoing initial assessment and ongoing management. As proposed earlier in the chapter, we believe the biopsychosocial framework, clinical reasoning strategies and hypothesis categories framework collectively highlight core areas of knowledge essential to holistic clinical reasoning. Together, these ideas can assist students and practicing physiotherapists to better understand and improve their own reasoning. Although cognitive processes such as cue perception,

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interpretation, planning and synthesis are integral to clinical reasoning, on their own they do not capture all that contributes to skilled reasoning. Additional factors, influencing proficiency in clinical reasoning, include critical thinking, higher-order metacognition, knowledge organization, data-collection skills and the therapeutic alliance between patient and therapist.

Reflection Point 3 Which of the different types of clinical patterns listed in Box 23.4 do you use in your clinical judgements? If there are some you agree are important but are not well developed in your working knowledge, you might consider building your knowledge of these through further study and peer discussions.

Factors Influencing Clinical Reasoning Critical Thinking Critical thinking involves analyzing and assessing information, issues, situations, problems, perspectives and thinking processes (Paul and Elder, 2007). It requires reflection and critique of assumptions embedded in current knowledge, reasoning and practice; openmindedness to other perspectives; critique of information regarding its accuracy, precision, completeness and relevance; and imagination to look beyond one's own perspective, including contemplation of possibilities beyond what is empirically known at the present time (Brookfield, 2008; Paul and Elder, 2007). Critical thinking underpins clinical reasoning and is a prerequisite to transformative learning where the assumptions of taken-forgranted perspectives are subjected to critical appraisal, leading to construction of new understandings and creation of new insights, knowledge and solutions (Mezirow, 2012). Everyone has assumptions that underpin what he or she believes, feels, knows and does. These assumptions manifest in different forms, including professional beliefs, values and stereotypical views about human nature and social organization that underpin

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our attitudes and actions. Becoming aware of your own perspectives and habitual ways of thinking and acting in practice, along with the assumptions that form the basis for those perspectives and actions, is an essential element of critical thinking and skilled clinical reasoning. That is, transforming habits of thinking requires critical reflection of the premises or assumptions underpinning your thinking. The need for this is not always obvious as people often acquire their beliefs/perspectives, points of views and habits of thinking unconsciously through their professional and personal experiences. As such, there is a tendency to fall back on what is available and familiar rather than critically appraising what you ‘know’ or believe. An example of a reflection on assumptions in clinical practice could include reflection on the biopsychosocial practice you believe you follow. Although physiotherapists may claim to adopt the biopsychosocial framework, frank reflection may reveal incomplete understanding and superficial attention to psychosocial factors in assessment and management (Singla et al., 2015). Unjustified assumptions in clinical practice can be minimized through a range of safeguards, including those listed in Box 23.5.

Box 23.5

Some Safeguards Against Unjustified Assumptions ▪ Qualifying patients’ meanings ▪ Screening to ensure information is not missed ▪ Testing for competing hypotheses ▪ Attending to ‘negatives’ or features of a presentation that do not fit favoured hypotheses and explanations ▪ Verifying your assessment of the patient's story with the patient ▪ Openly subjecting and comparing your own reasoning to others

Metacognition 572

In addition to physiotherapists’ critical thinking and analytical skills, their metacognitive skills also influence their clinical reasoning proficiency. Metacognition is a form of reflective selfawareness that incorporates monitoring of yourself (e.g., your performance, your thinking, your knowledge) as though you are outside yourself observing and critiquing your practice. There is an integral link among cognition (i.e., perception, interpretation, synthesis, planning), metacognition and learning from clinical practice experience (Higgs et al., 2008). For example, following protocol assessments can require little cognition beyond remembering a routine. In contrast, questions and physical assessments can provide a more complete picture of the patient's presentation if the specific purpose is to test working hypotheses or recognize clinical patterns. Although, hopefully, all therapists think, not all therapists think about their thinking. It is this self-awareness and self-critique that prompt the metacognitive therapist to reconsider his or her hypotheses, plans and management. This self-awareness is not limited to testing formal hypotheses and thinking about treatments. Metacognitive awareness of performance is also important. This, for example, underpins the experienced therapist's immediate recognition that a particular phrasing of a question or explanation is not clear to a patient. Similarly, metacognitive sensitivity enables immediate recognition that a procedure needs to be adjusted or perhaps should be abandoned. For example, cues such as an increase in muscle tone or the patient's expression can signal a procedure is not achieving its desired effect. Effective metacognition contributes to the responsibility (that the physiotherapist shares with the patient) for fully understanding the patient versus simply ‘judging or labelling the patient’ and consequently relieving the physiotherapist of responsibility for the outcomes of care. Lastly, metacognition is important to recognizing limitations in knowledge and ability. The student or therapist who lacks this metacognitive awareness will learn less. Experts not only know a lot in their area of practice, but they also know what they do not know. That is, the expert is typically very quick to recognize a limitation in his or her knowledge (e.g., a patient's medication he or she is unfamiliar with, a medical condition, the distribution of a peripheral sensory or motor nerve) and act on this by consulting a

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colleague or appropriate resource. In short, metacognition and critical reflection are important means to continue professional career-long learning.

Data Collection and Procedural Skills Clinical reasoning is only as good as the information on which it is based. Incomplete and inaccurate information obtained through the patient interview, physical examination and monitoring of outcomes (during and after treatments) can lead to inaccurate analyses that compromise specific treatment and overall management. Broadly, the patient interview (supplemented by review of available records) serves the purpose of obtaining information to understand the problem(s) and the person. It also provides the initial means for developing an effective patient– therapist therapeutic alliance, as discussed later in the chapter. Each area of physiotherapy practice will have its own core routine information sought within the patient interview. This core information needs to be complete and accurate and applies to all patients. The breadth of this information will then be complemented by the depth needed to understand individual patients in their uniqueness and clarify what is meaningful for them. There are many situations in which patient responses require clarification to accurately understand their meaning. For example, patients’ perceptions of their problems may be based on superficial accounts of what their doctors, or others, have told them. Our assessments need to find out what these perceptions actually mean to the patient with respect to the cause, management and the future. Clarifying relationships between beliefs, cognitions, emotions and behaviours with the history and behaviour of the patient's symptoms and disability helps identify the key factors contributing to a patient's pain/disability experience. Explicit ‘Screening Questions’ that assess beyond what the patient spontaneously offers, such as screening for other symptoms, aggravating or easing factors and screening general health, are examples of ways to establish this completeness. As with the patient interview, the quality of information obtained from the physical examination is influenced by the

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physiotherapist's procedural skills. Errors in subjective assessments of physical tests (e.g., posture, range of active and passive movement, kinematics, judgements regarding stiffness, laxity/instability, motor performance and soft tissue) underpin the importance of using reliable objective measures and diagnostic procedures with the greatest validity, wherever possible. When objective measurement is not available, findings should be rechecked for consistency, related to other findings (e.g., passive accessory movement findings compared with physiological movement findings) and cautiously integrated with more objective findings to guide reasoning judgements.

Knowledge Organization The importance of knowledge to physiotherapists’ clinical reasoning is highlighted in Jensen's expertise research. Expert physiotherapists were seen to possess a broad, multidimensional knowledge base acquired through professional education and reflective practice where both patients and other health professionals were valued as sources for learning (Jensen et al., 2007). Well-structured knowledge is essential to domain competence. Research in cognitive psychology and artificial intelligence (e.g., Greeno and Simon, 1986), categorization (e.g., Hayes and Adams, 2000), expertise (e.g., Boshuizen and Schmidt, 2008; Jensen et al., 2007) and education (e.g., Pearsall et al., 1997) have collectively demonstrated the importance of well-developed knowledge to successful performance. Well-structured knowledge is not simply how much an individual knows but how that knowledge is organized. For knowledge to be accessible in practice, it needs to be linked to practice. All forms of knowledge are important, including clinicians’ broader worldviews, their philosophy of practice and their medical and profession specific knowledge. The ICF biopsychosocial model and the clinical reasoning strategies and hypothesis categories frameworks provide means for physiotherapy knowledge organization that directly link theory to practice. Physiotherapy theory continues to grow in unison with the growth in research across the sciences and health professions. Equally important, but generally with less research attention, is our professional craft

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knowledge (Higgs et al., 2008). Craft knowledge comprises professional knowledge such as procedural, communication and teaching knowledge and skills. It is underpinned by theory (e.g., anatomy, biomechanics, neurophysiology, psychology, sociology) that has been contextualized through clinical experience. Although clinical trials, clinical guidelines, clinical prediction rules and theory extrapolated from basic science all provide helpful guides to management for different problems, as mentioned at the start, these should not be taken as prescriptions (Greenhalgh et al., 2014). Instead, physiotherapists must judge how their patient matches the population in the research reported and then tailor their management to the individual patient's unique lifestyle, goals, activity and participation restrictions, perspectives, pain type, potential pathology and physical impairments. Because researchsupported management efficacy is still lacking for most clinical problems, advanced theoretical and craft knowledge, combined with skilled reasoning, is the physiotherapist's best tool to optimize management effectiveness for individual patients.

Therapeutic Alliance Ferreira et al. (2013, p. 471) define the therapeutic alliance as ‘the sense of collaboration, warmth, and support between the client and therapist’. The manner in which an examination and therapy are provided is important, especially with respect to patient rapport. If the physiotherapist shows interest, empathy and confidence, then patients are likely to respond positively. Patients are more willing to volunteer relevant information, more willing to participate in self-management, and more motivated to change (Ferreira et al., 2013; Hall et al., 2010). Although the patient interview and physical examination are largely about gaining information to understand the patient and his or her problems, the nature and manner in which this is done are all important. The tone of voice, the nonverbal behaviours, the time allowed and the responses to patients all affect how a patient perceives the therapist. These factors are a strong influence on the confidence of the patient and the success of the therapeutic relationship (Ferreira et al., 2013; Hall et al., 2010). The patient–therapist relationship is founded on the perceptions

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each has about the other and by how each person perceives and understands him or herself (and his or her roles) as a ‘self’. Merleau-Ponty offered a concept of the ‘self’ as embodied (1962, p. 137), meaning that a person's sense of self (and his or her consciousness) is expressed in the physical and social world of that person via such things as his or her gestures, movements and actions. The idea of embodiment helps us understand that illness or disability ‘is not simply a biological dysfunction of a body part but a pervasive disturbance of our being in the world’ (Carel, 2012, p. 326). In other words, pain and disability can profoundly affect a person's sense of self and how he or she experiences his or her ‘place’ in the world. Our questions and responses (verbal and nonverbal) are interpreted by patients with pain and disability from this position of a changed sense of self (Greenfield and Jensen, 2010). If we forget this, then in our clinical reasoning conclusions, we can reduce the experiences of a person with pain and disability to a merely prescriptive label, such as ‘pain behaviour’, and we can then also reduce his or her capacity to act for change (Edwards et al., 2014; Ricoeur, 2006). Sensitivity to embodiment needs empathy. Empathy in a clinical context refers to therapists’ cognitive abilities to understand what their patients are experiencing and therapists’ affective abilities to imaginatively project themselves into their patients’ situations (Braude, 2012). Having and conveying empathy are probably personal skills acquired throughout life. When empathy is applied in practice, patients are more likely to feel they have been given a voice, have been heard and have been believed, all of which strengthen the therapeutic alliance. Many patients report negative experiences with medical and other healthcare professionals whom they felt did not listen or believe them (e.g., Edwards et al., 2014; Epstein et al., 2005; Johnson, 1993; Payton et al., 1998). Without good rapport and empathy, the patient is less likely to collaborate, potentially compromising clinical reasoning and jeopardizing the eventual outcome. The importance of empathic collaboration (as in the reasoning strategy collaborative reasoning), not simply cooperation, is underscored by the evidence that patients who have been given an opportunity to share in the decision making take greater responsibility for their own management, are more satisfied with their health care and have a greater likelihood of achieving better outcomes (Arnetz et al., 2004;

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Edwards et al., 2004b; Trede and Higgs, 2008).

Chapter Summary In this chapter, we have outlined:

▪ the critical need for physiotherapists to understand the components of clinical reasoning including common errors in human judgement, fast and slow reasoning processes and the critical role of adaptive expertise, ▪ how clinical reasoning fits within a biopsychosocial framework and is aligned with the ICF model, ▪ a framework of clinical reasoning strategies that provides assistance to understanding and learning clinical reasoning, ▪ a framework of hypothesis categories, or clinical judgements, required across the different clinical reasoning strategies and ▪ factors that influence clinical reasoning, including critical thinking, metacognition, knowledge organization and the therapeutic alliance. Reflection Point 4 How can you synthesize the ideas, frameworks and strategies presented in this chapter into a coherent model to guide your own clinical reasoning?

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24

Clinical Reasoning in Dentistry Shiva Khatami, Michael Macentee, Stephen Loftus

CHAPTER AIMS The aims of this chapter are to: ▪ present a conceptual framework for clinical reasoning in dentistry, ▪ identify the sources of uncertainty in clinical reasoning of dentists and ▪ provide direction for future research and education of clinical reasoning.

KEY WORDS Clinical reasoning Uncertainty Dental education

ABBREVIATIONS/ACRONYMS H-D Hypothetico-deductive PBL Problem-based learning

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WHO World Health Organization

Evolution of Clinical Reasoning Clinical reasoning is a core component of healthcare practice. It involves a process of thinking and interacting with ‘problem spaces’ within a multilayered context of the clinician, the patient and the clinical problem, surrounded by a larger social, cultural and global environment. Using this interactive and interpretive process, clinicians attempt to understand clinical situations, make diagnostic and therapeutic decisions and frame and solve clinical problems (Khatami et al., 2012). Historically, healthcare professions have evolved their awareness of the scope and diversity of health-related problems. From the birth of scientific health care (Foucault, 1994), the biomedical model has dominated how the health professions conceptualized health and disease (Adams, 1999). More recently, other models, such as ‘sick role theory’ (Parsons, 1951), have challenged the biomedical model. Subsequent emphasis on the patient's role in health care led to development of the biopsychosocial model of health care (Engel, 1977). From this perspective, the concept of health has evolved to include a general feeling of physical, psychological and social wellbeing or, according to Svenaeus (2000), a sense of ‘homelike being in the world’ (p. 114). Dentistry has seen a parallel evolution from treating disease to treating the whole person within a specific sociocultural context (Khatami and MacEntee, 2011) and beyond a predominantly surgical approach (e.g., extractions and fillings) to include a more medical and preventive model of care (Baelum and Lopez, 2004). A focus on prevention has highlighted the social and behavioural context of diseases together with a need for equitable access to oral healthcare services. The focus now on equity has broadened dental practice from private dental clinics to hospitals, schools, community-based clinics and long-term care facilities, along with an interdisciplinary approach to care (Field, 1995; Formicola et al., 2006). The advent of telemedicine and teledentistry will further expand the context of dental practice from physical to virtual interactions with patients and peers (Daniel and Kumar, 2014).

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After the Institute of Medicine report was published (Field, 1995), dental educators were challenged to accommodate a broader awareness of environmental and psychosocial determinants of health in an already crowded professional curriculum focussed narrowly on science and psychomotor skills (Hendricson and Cohen, 2001; MacEntee, 2010). Alternative curricular models emerged promoting problem-solving skills, developing competencies and community-service learning (Khatami and MacEntee, 2011). However, the effectiveness of these curricular models is unclear in developing and evaluating the clinical reasoning of dentists, possibly due to limited understanding of the process of clinical reasoning. It is worth taking a short look at the history of how clinical reasoning has been understood in dentistry.

Exploring Clinical Reasoning Inconsistencies in diagnosis and treatment planning revealed by earlier psychometric studies resulted in repeated calls for sensitive and specific diagnostic tests, practice guidelines and decisionsupport systems for dentists (Kay et al., 1992; Kawahata and MacEntee, 2002). Decision analysis, preference-based measurement, rating scales, standard gamble techniques, time trade-offs, qualityadjusted life (tooth) years, game theory and Bayesian-based utility measures have all been applied as theoretical bases for exploring decision making in dentistry. These approaches collectively come under the banner of medical decision theory (Matthews et al., 1999). Decision analysis applies a sequential process of developing and revising diagnostic and treatment decisions by constructing and proceeding along the trunk and branches of decision trees (Kawahata and MacEntee, 2002). Bayesian rules are applied to weigh all possible decisions by identifying the expected outcomes, estimating their probability, evaluating their risks and benefits and assigning a utility value to each. The probability and utility values are evaluated to reach the most ‘rational’ decision. However, Chambers et al. (2010) found that applications of Bayesian formulas to epidemiological data were not a typical part of how dental students or experienced dentists made decisions about the presence or prognosis of disease. The uncertainty of available evidence frequently compromises confidence in diagnosis of pathologies

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(Pena and Andrade-Filho, 2009). Moreover, rational treatment decisions based on the rules of decision analysis can conflict with the patient's preference for treatment and the clinician's ethical principles (Patel et al., 2002). Decision trees require a certain degree of artistry; however, the creativity for constructing and interpreting them can contradict the conceptual framework of decision theory. Bayes’ theorem informed the development of earlier computerbased decision support systems for diagnosis and treatment planning in dentistry (e.g., Sims-Williams et al., 1987), followed by neural networks (e.g., Brickley and Shepherd, 1996) and fuzzy logic (e.g., Wang et al., 2016). There has also been an emphasis on language, symbols and semantics within the context of dentistry, even in the presence of uncertainty (Kawahata and MacEntee, 2002). Symbolic computations, such as fuzzy logic, for example, offer the possibility of managing uncertainty in rule-based clinical decisions (Zadeh, 2008). However, decision support systems such as those used in telemedicine and teledentistry apply essentially reductionist methods to solving problems and pose ethical and legal concerns when there is inadequate empirical evidence to support the decision recommended by the system (Goodman, 2007). Computerized systems cannot always manage the multilayered meanings within the clinical interactions between patient and dentist (Loftus, 2015). However, support systems offer educational opportunities for practicing diagnostic and treatment decisions on virtual patients (Cook et al., 2010). The hypothetico-deductive (H-D) model has been the dominant theory explaining how experienced dentists move through ‘forward reasoning’ to search, identify and organize key points of information and generate a diagnosis (Crespo et al., 2004). Dental students and novice dentists usually start this diagnostic process by generating a list of hypotheses and working backwards to confirm or reject each hypotheses. Experts usually move more rapidly by acknowledging the influence of psychosocial issues on their decisions and relying on experience to recognize patterns or ‘illness scripts’ from previous clinical encounters (Charlin et al., 2000). From this viewpoint, for example, caries is recognized from a script describing the colour and size of demineralized dental lesions (Bader and Shugars, 1997). Dental students, in contrast, tend to use a more laborious ‘dual processing’ model with H-D reasoning and

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pattern recognition to the same end (Maupomé et al., 2010). However, the accuracy of diagnosis between one ‘system’ versus the other is unclear (Monteiro and Norman, 2013). Alternatively, a narrative explanation posits that experienced dentists, unlike computers, are sensitive to the intricate beliefs and behaviours of their patients, which points to the need for more inductive and interpretive explorations of how dentists, like other clinicians, work towards making clinical decisions (Loftus, 2015). For example, encounters with anxious patients can be eased by allowing patients to tell stories that explain their clinical problems beyond the more typical biomedical narrative of disease. Dentists can also benefit from developing phrónêsis or a practical disposition to act wisely when confronted by an unusual clinical situation (Kinsella and Pitman, 2012). Apparently, phrónêsis is acquired by practical encounters, especially when clinicians have opportunities to reflect on what they learned from each encounter (Schön, 1983). The development and sharing of such stories allow clinicians to acquire practical wisdom that they recall when confronted later by similar problems.

Conceptual Framework Fig. 24.1 portrays a conceptual model of clinical reasoning in dentistry developed from studies of dental students and specialists across different levels of expertise (Khatami, 2010). The multilayered context of clinical reasoning is shown as overlapping ovals integrating the personal frame of reference of the dentist, the frame of reference of the patient, the problem(s) and the larger healthcare environment. The following describes the components of the model and the similarities and differences in reasoning of dentists across different levels of expertise and problems.

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FIG. 24.1 Conceptual framework for clinical reasoning

in dentistry.

Processes of Clinical Reasoning Ritual The notion of ritual is borrowed from the field of medical anthropology and plays a role in many aspects of health care (Helman, 2007). We use it here to emphasize that following a systematic and standardized approach is not new or exclusive to science or health care. Most dentists follow a systematic approach to acquire medical, dental and social histories and evaluate clinical data and diagnostic aids, such as radiographs and study models. Subsequently, they plan a sequence of treatment, usually starting with management of disease, followed by rehabilitation and maintenance of health. Being familiar with the routines and rituals of assessment means that one can concentrate on the goal of reaching a diagnosis without having to explicitly remember all the details that need to be included in the process. With practice, the routines and rituals become embodied and automatic. An expert

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can be sure that the relevant questions and procedures will be addressed. Beyond this, more experienced dentists seem to have individualized rituals and routines that allow them to reason rapidly and efficiently and collect only information pertinent to the case. This may be because experienced clinicians are keenly sensitive to what is salient in a particular setting (Benner et al., 2011).

Backward (Deductive) and Forward (Inductive) Reasoning Although it is often said that experts tend to reason in a forward direction and novices in a backward direction, this is not always the case (Laufer and Glick, 1996). It is more likely that experienced dentists go backwards and forwards to diagnose clinical problems. Even in forward reasoning, experts will form several tentative diagnoses early in the process. Experts typically hold tentative diagnoses lightly and change their focus as information is gathered, whereas novices, often restricted to a backwards process of reasoning, tend to remain firmly attached to the initial diagnoses, as others have explained within the context of critical thinking (McKendry, 2015).

Pattern-Recognition Through Scripts Visual and descriptive cues help dentists recognize the pattern of specific diseases, such as caries, periodontal disease and other abnormalities. These allow the dentist to bypass unconsciously the intricate processes of making and testing hypotheses. Demineralized carious lesions on teeth present in a wide range of colours, appearances and textures from which a dentist can define a pattern recognized from previous experiences. However, assessing the aetiology and risk for caries and tooth loss requires a more elaborate exploration that extends from physical to psychosocial considerations (Baelum, 2010). The ‘caries scripts’ often consist of information about the composition of saliva and oral bacteria and details of a patient's diet, hygiene and socioeconomic status that leads to an assessment of ‘caries risk’ and therapeutic options. Similarly, visual cues about the normal versus abnormal

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appearance of gingiva and periodontium trigger the scripts for gingivitis and periodontal disease (Baelum and López, 2004). However, to classify the severity of each disease and appropriate treatment, additional clinical and possibly radiographic information is required.

Decision Analysis Most dentists do not quantify the probability or utility value associated with Bayes’ theorem. Instead they integrate their knowledge and experience practically to interpret the problem and select treatment options (Chambers et al., 2010; Khatami et al., 2012).

Clinical Reasoning Strategies The following reasoning strategies help dentists interpret and address clinical problems.

Scientific Reasoning The H-D process of reasoning, described earlier, follows a scientific method of systematically observing, measuring and collecting information, followed by the formation, testing and modification of hypotheses or tentative diagnoses (Khatami et al., 2012). However, as explained earlier, the experienced clinician usually brings professional experience and common sense to the reasoning process in ways that seem to increase directly with the extent of clinical uncertainty.

Conditional Reasoning Predicting the prognosis of treatment needs biological, psychological and socioeconomic measurements tempered by clinical experiences and pattern recognition. Nonetheless, the uncertainty of treatment outcomes challenges most clinical decisions. Consequently, conditional reasoning helps anticipate and reduce future problems through a tentative or wait-and-see approach whereby the clinician defers definitive or irreversible

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decision until the uncertainty is reduced to a level agreeable to both the dentist and patient (Khatami, 2010).

Collaborative Reasoning Communicating with patients and colleagues is an integral part of good clinical practice. It should aim to share the responsibility of making decisions and an understanding of the most desirable and feasible treatment outcome available, especially when treatment involves a change in the patient's beliefs and behaviour (Khatami et al., 2012).

Narrative Reasoning This strategy manages the experience and multilayered meaning of disease and health from the perspective of patients and how they influence health-related behaviours and expected treatment outcomes. Reflecting on the assumptions that dentists bring to this interpretive process allows them to compare their own values and beliefs with those of a patient. This might include stories of previous encounters with similar problems that help to interpret the current situation and offer similar treatment options (Khatami, 2010).

Ethical Reasoning Principle-based ethics have dominated the way many dentists resolve problems; however, virtue and narrative ethics provide greater scope for dealing with the difficulties of clinical uncertainty (Charon et al., 2016). Virtue ethics dwells more on developing the moral character of the dentist through personal reflection and allowance for personal strengths, weaknesses and motives rather than on ethical generalities that hallmark the principled approach to ethical practice (Oakley, 2016). Similarly, narrative ethics dwells directly but broadly on individual needs with all the nuances and contradictions that permeate the life of each patient (Geisler, 2006). It explores problems and solutions through the unique experiences of each participant.

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Pragmatic Reasoning This strategy offers a pragmatic approach to the issues relating to the social, economic, or political environment of the healthcare system. Availability of resources, risks and benefits and costeffectiveness of treatment modalities and abilities of the clinician to deliver the required care often influence the approach to care from idealistic or theoretical to realistic and practical (Schell, 2008).

Part-Whole Reasoning Several reasoning strategies are used as clinicians focus in and out of different ‘conceptual spaces’; refocus on different aspects of a clinical problem; move from one problem to another; and decide how all the parts relate to the patient as a whole (Fiorini et al., 2014; Khatami et al., 2012). Often, interpreting problems and evaluating options for treatment involve a combination of analytical and nonanalytical reasoning processes, integrating several reasoning strategies and moving from a specific problem to consider the larger context in which the problem occurs. Part-whole reasoning is also a significant part of hermeneutic reasoning (Svenaeus, 2000).

Case Study 24.1

Considering Different Clinical Decisions – What's Your Opinion? Angela is a 74-year-old retired teacher who presents to your practice with Wendy, her daughter. Angela does not speak English. She moved from China 4 years ago to live with Wendy and her family. Wendy tells you that you are the third dentist they have seen this week. They are frustrated with the high cost of treatment suggested by the previous dentists to replace missing teeth, and Angela does not have dental insurance. Her medical status includes high blood pressure, which is currently under control, and Parkinson's disease. Angela is missing all posterior teeth and has a crowned upper-left central incisor that is sensitive to cold. She has abraded away about half of her lower incisors, but this does not concern her. Wendy asks if you could

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replace all of her mother's teeth with complete dentures to minimize the cost of treatment. How would you address this request?

Key Features in Clinical Reasoning of Dentists A personal frame of reference is a major feature of how dentists interpret problems, assess treatment options and make clinical decisions (Khatami et al., 2012). They draw on past experiences to recognize the pattern of problems or diagnostic and management scripts. Novice dentists typically follow strict rules or rituals to collect information and plan treatment. Experienced dentists use more flexible routines in response to the familiar patterns of common problems, the expectations and motivations of their patients and their own personal context for prioritizing problems, and they plan interventions accordingly (Khatami, 2010).

Reflection Point 1 How does your personal frame of reference influence your approach to Angela's care?

Uncertainties in Clinical Reasoning The uncertainty of clinical practice poses a significant challenge to all clinical practitioners, from students to mature clinicians. Fox (1980) observed that medical students struggle with three domains of uncertainty: 1) their own incomplete mastery of available knowledge; 2) the limitation of available knowledge; and 3) the distinction between their personal limitations and their emerging awareness of the limitations of the profession at large. In addition, they are readily confused by different approaches to analyzing and addressing clinical problems, especially when confronted by unpredictable responses from patients. Beresford (1991) explained the technical, personal and conceptual uncertainties of clinical practice. He identified technical uncertainty in the limitations of

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scientific evidence and personal uncertainty in the limitations of the clinician's knowledge and experience, compounded by the unpredictable response of patients. Finally there is conceptual uncertainty in the clinical application of incommensurable criteria to the concrete problems of patients. Han et al. (2011) define uncertainty as a subjective perception of ignorance constructed and managed ‘through the interactions of patients and health professionals’ (p. 834). They proposed an organized conceptual taxonomy or framework that is sufficiently broad to account for the full range of salient issues experienced by patients and clinicians yet narrow enough to be meaningful and practical. They believe that practically patients worry about uncertainty pertaining to the probability of beneficial treatment, the ambiguity of accompanying advice and the complexity of the disorder itself, especially because these issues are frequently unquantifiable scientifically, practically or personally. Identifying the issues and sources of uncertainty in this manner, they contend, will enable the clinician to reduce them to the extent warranted by each patient. However, they stress, the therapeutic goal is not necessarily to eliminate uncertainty but rather to acknowledge it within the bounds of current knowledge and enable patients to make informed decisions. More experienced clinicians are more likely to admit their uncertainties and develop a professional rhetoric of uncertainty when confronted by technical, personal or conceptual uncertainties (Lingard et al., 2003). Katz (1984) reminds us that physicians have a long history of therapeutic deception by hiding uncertainty from patients to enhance the placebo effect in the practice of medicine. Justification for masking uncertainty, he believes, depends on the ‘kinds of faith, hope and reassurance’ (p. 40) that a patient seeks from a doctor, and the patient must make this decision. This dilemma illustrates quite clearly the ongoing conflict between art and science in clinical decisions, a dilemma that also confronts dentists (MacEntee, 2007). Relationships between clinicians and their patients are strongly influenced by the professionalism and communication skills of the clinician. Denial of uncertainty can be a deceptive strategy to create an illusion of control leading to a dogmatic certainty that brings bias and error to clinical reasoning (Katz, 1984; MacEntee and Mathu-Muju, 2014).

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Reflection Point 2 Which of the technical, personal or conceptual uncertainties influence your clinical reasoning in everyday practice? How do you communicate uncertainty to your patients? Light (1979) argued that the degree of technical uncertainty in each profession reflects the paradigm development underlying its practice and the paradigm strength explaining the phenomena it addresses. However, Knafl and Burkett (1975) referred to treatment philosophies in a context similar to paradigm development but concluded from an ethnographic study of residents in orthopaedic surgery that the ‘fundamental importance attached to personal clinical experience in the exercise of judgement may lead physicians to reject established scientific opinion in favor of personal preferences’ (p. 403). The prognosis of dental treatment, as in all health care, is often difficult to predict. Uncertainties are exacerbated beyond the personal professional realms of patients and dentists by different philosophies of care and conflicting opinions within and across different specialties (Knafl and Burkett, 1975). The availability, validity and quality of evidence are inconsistent both within and across the specialties. Advances in biomaterials, computer-aided design/computer-aided manufacturing (CAD/CAM) and treatment modalities are rapid, challenging, uncertain and ongoing (Marinello, 2016). The validity and reliability of diagnostic indicators for caries, periodontal disease and other disorders of the mouth are all subject to interpretive challenges (Baelum, 2010; Baelum and López, 2004; Fuller, 2015). The market trend and media may also influence the demand for specific dental treatments and approaches to care even if untested or lacking good supportive evidence (MacEntee, 2005; Newsome and Langley, 2014). Discrepancies in priorities and definitions of treatment objectives by clinicians, patients and third-party payers create conflict of opinions and interests and often lead to uncertainties and ethical dilemmas. The cost of treatment and coverage of the cost by dental insurances can influence patients and ultimately clinicians’ choices for treatment (Vernazza et al., 2015).

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Sometimes treatment is postponed or rejected when a dental insurer does not cover the cost. Inconsistencies and unclear definitions for standard of care lead to ethical dilemmas, fear of litigation and neglect of appropriate care (Bryant et al., 1995). Respecting a patient's autonomy can clash with the ethical principles of the clinician. Furthermore, a collaborative approach involving several clinicians in search of optimal care can be a double-edged sword. There is shared responsibility for managing uncertainty but also shared legal liability for the outcome. Indeed, this fear of litigation may sway many clinical decisions towards an overly conservative and possibly ineffective approach to treatment.

Assessment of Clinical Reasoning The acquisition of skills to think critically and reason competently in clinical situations is a continuous and dynamic process, extends beyond predoctoral education and poses an assessment challenge for dental educators (Khatami and MacEntee, 2011). There is little evidence that dental educational methods based on problem-based learning (PBL) and the H-D model of problem solving can enhance the critical skills of dental students (Whitney et al., 2016). Moreover, uncertainty around the competency needed for dentistry in this dynamic environment tests the assessment methods currently used in dental education. Comparison of dental competency statements from Europe and the Americas reveals notable differences in format, detail and expected outcomes (American Dental Education Association, 2015; Plasschaert et al., 2005; Whitney et al., 2016). As in all healthcare disciplines, there is no common language or core of professional competencies. Consequently, dental educators struggle to define competencies appropriate to specific regions or modify existing competency statements from other regions (American Dental Education Association, 2015; Plasschaert et al., 2005).

Reflection Point 3 How has your competency in clinical reasoning evolved in the course of your professional development?

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Recent statements highlight the importance of professionalism, critical thinking, information management and decision-making for competent patient care (American Dental Education Association, 2015; Newsome and Langley, 2014). PBL and the H-D model of problem solving continue to dominate the learning environment and assessment methods in dental education despite questionable achievements in teaching clinical reasoning (Whitney et al., 2016). Nonetheless, despite the limitations of PBL, there remains the likelihood that clinical learning will be enhanced by Ericsson's (2004) concept of deliberate practice in which diagnosis and treatment planning in a classroom or virtual settings encourage the development of the knowledge networks required for clinical reasoning, through a process of repetition, reflection and feedback (Eva, 2005; Khatami et al., 2012). Dental educators still rely heavily on multiple-choice questions and the objective structured clinical examination (OSCE) to assess professional competency, although with increasing concerns about their construct or predictive validity (Albino et al., 2008). There is now an awareness of the need to revise and probably replace these methods so that the public can be assured that a newly graduated dentist has ‘at least minimal levels of competence on many different fronts’ (Karimbux, 2013, p. 1555).

Chapter Summary It is through clinical reasoning that dentists, like other clinicians in health care, understand and solve clinical problems. Competent dentists make reasonable clinical decisions in a multilayered problem space that encompasses the social, cultural, political and economic environments in which they and their patients live. Their reasoning involves a nonlinear but typically recursive process of investigation and intervention involving both analytical and nonanalytical reasoning, dictated by the problem at hand and by previous experiences. The frame of reference guides the decision process along interpretive paths where problems are identified, assessed, prioritized and managed preferably through a shared understanding of the uncertainty by both the dentist and patient. Competent dentists integrate a mix of reasoning strategies to form and implement effective treatments. In practice, they zoom in

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and out of problems from a local anatomical level to the wider psychosocial context in which their patients live. They are sensitive to uncertainties that arise from their limitation of knowledge and skills. They are aware also of the complexity of oral health–related problems and unpredictable outcomes of interventions. They acknowledge the limitations of diagnostic aids and multiple interpretations of clinical information, and they wrestle constantly with conflicts between ethical principles, fear of litigation and conflicting priorities of patients, colleagues and others involved in paying for health care.

Reflection Point 4 How do the reasoning strategies introduced in this chapter help identify and address the uncertainties involved in your clinical reasoning?

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Clinical Reasoning in Occupational Therapy Christine Chapparo, Judy Ranka

CHAPTER AIMS The aims of this chapter are to examine clinical reasoning in occupational therapy from four perspectives, including: ■ a brief history of clinical reasoning in occupational therapy, ■ the content of therapist thinking that has been found to influence occupational therapy action, ■ the conceptual notions about the thinking processes that underpin clinical decision making in occupational therapy and ■ how occupational therapists may use cognitive strategies during the process of reasoning.

KEY WORDS 608

Diagnostic, procedural, conditional, pragmatic and ethical reasoning Personal beliefs Cognitive strategy use

ABBREVIATIONS/ACRONYMS OT Occupational therapy OTs Occupational therapists PRPP Perceive, Recall, Plan and Perform system of task analysis

Introduction Answers to six questions lie at the heart of occupational therapy (OT) assessment and intervention, which is a complex, dynamic process based on observation of the interaction between people and their environments as they perform relevant and valued everyday activity. 1. What is the situation? 2. What is wanted/needed/possible in this situation? 3. What will I do? 4. How will I do it? 5. Why am I doing it? 6. Did it work? People access OT when they, family and community members or other professionals perceive that they are not adequately performing their daily occupations or activities. Disruptions to occupational performance are inherently complex, severe and enduring, affecting all ages and sociocultural backgrounds. OT can be applied in many situations such as medical, community and educational. Both social services and private practices may use OT. The professional practice of all therapists is affected by a configuration of demographic, social, cultural, political, technological or epidemiological sources, contributing to the complexity of therapy. Under conditions of such complexity,

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uncertainty and change, occupational therapists aim to develop and implement therapy programs that support clients and their families to participate in desired life skills and ensure their quality of life. ‘Thinking like a therapist’ is critical to selecting the ‘right’ therapeutic intervention for a particular setting and implementing it in the interest of each client. For over three decades, therapist thinking in OT has been termed clinical reasoning (Mattingly and Fleming, 1994). It is a nonlinear, recursive style of thinking that involves gathering and analyzing client information and deciding on therapeutic actions specific to a client's circumstances and wishes. It combines cognitive and metacognitive strategies such as analysis, problem solving and evaluation together with precognitive intuition. Finally information is synthesized with visualization of the client's future needs in his or her unique physical, social and cultural context (Durning et al., 2011). Although the importance of reasoning in OT has been clearly established (Mattingly and Fleming, 1994), it remains a hypothetical construct, the understanding of which has continued to evolve (Unsworth, 2011). Several questions remain unanswered about the thinking processes used in clinical reasoning. What personal and contextual elements are involved in the reasoning process? How do therapists combine science, practical knowledge and their personal commitments to make decisions about their actions? Why do therapists make decisions the way they do?

Clinical Reasoning in Occupational Therapy: Historical Perspective Throughout the development of OT, clinical reasoning has been referred to as treatment planning (Day, 1973), the evaluative process (Hemphill, 1982), clinical thinking (Line, 1969), a subset of the OT process (Christiansen et al., 2005) and problem solving (Hopkins and Tiffany, 1988). The clinical reasoning process has been described as a largely tacit, highly imagistic and deeply phenomenological mode of thinking, ‘thinking about thinking’ (Schell and Schell, 2008). More recently, there has been a move away from use of the term ‘clinical reasoning’ in preference to ‘professional reasoning’ (Turpin and Iwama, 2011, p. 33) and

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‘occupational reasoning’ (Rogers, 2010, p. 57). This is because many therapists are employed outside clinical settings and provide interventions for ‘clients’ and ‘people’ rather than ‘patients’. Current understandings of clinical reasoning have been influenced by the diverse nature and goals of OT practice, the philosophical development of the profession itself and the various epistemologies of individual researchers. OT was founded on humanistic values (Meyer, 1922). The view of occupation that was accepted by the profession early in its development centred on the relationship between health and the ability to organize the temporal, physical and social elements of daily living (Keilhofner and Burke, 1983). Therapy depended on an analysis to understand the unique significance and meaning of activity in a person's everyday life. Today's practice continues this, using the notion of health and ability for all and with a social awareness that locates disability, illness and the need for therapy in exclusionary social, economic and cultural barriers to human occupational performance (Townsend and Polatajko, 2007). OT thinking is increasingly seen in nontraditional public health roles such as aid agencies (Kronenberg et al., 2011). Public policy has become an everyday working arena for occupational therapists, requiring the use of reasoning skills to determine how occupational performance fits with social need (Braveman and Suarez-Balcazar, 2009). The development of medical and rehabilitation paradigms in the middle of the 20th century influenced how OT clinical reasoning was conceptualized. Therapists sought kinesiological, neurophysiological and psychodynamic explanations of human function and dysfunction (Molineux, 2011). Clinical decision making focussed on improving isolated units of function, such as particular physical or psychological attributes. Systems approaches were used to explain and teach clinical reasoning (Box 25.1).

Box 25.1

Systems Approach to Clinical Reasoning Day (1973) created a unidirectional model of decision making comprising problem identification, cause identification, treatment

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principle or assumption selection, activity selection and goal identification. Central to this model was a procedural reasoning style that continues to be recognized as one element of therapist thinking. The last two decades have seen a resurgent demand for scientific reasoning prompted by evidence-based practice that assumes a systematic approach to therapist thinking (Taylor, 2000). Derived from medicine, evidence-based decisions were, originally, to be made by integrating knowledge of individual client characteristics and preferences, together with the therapist's clinical experience and evidence from clinical research in the formulation of clinical decisions (Sackett et al., 1996). An evidence-based approach to clinical reasoning emphasizes knowledge generated by randomized controlled trials and statistical measurement (National Health and Medical Research Council, 2009). It can be argued that assumptions that underpin this view of evidence include:

■ health is a simple construct that can be measured the same way for all people and ■ ill health and disability can be reduced to small units of measurement that accurately reflect a larger problem. The influence upon OT thinking is clear. Contemporary writers frequently prefer clinical reasoning based on evidence established by certain kinds of research only. The client's input and the therapist's expertise tend to be downplayed. In these instances, clinical reasoning has been described as not aligned with the social rights to health (Di Constanzo, 2012) and therefore distant from the original focus of OT. In summary, OT practice in the 21st century continues to be characterized by theoretical conflict, as the profession reexamines its direction and focus (Molineux, 2011; Turner and Knight, 2015). A number of theories, models and frames of reference have emerged to explain the concept of occupation, the purpose of OT and to guide practice, each with an associated reasoning pathway. The original belief in clients’ rights to choice and autonomy is reflected

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in the phenomenological and hermeneutic approaches that have largely been used to study OT clinical reasoning, and the influence of medicine on clinical reasoning is illustrated by the analytic EBM (Evidence-based medicine) approach.

Reflection Point 1 OT clinical reasoning processes will continue to form a basis for OT identity. Their importance was summed up by Pedretti (1982, p. 12), who stated, ‘perhaps our real identity and uniqueness lies not as much in what we do, but in how we think’.

Knowledge and Clinical Reasoning in Occupational Therapy There are both internal and external influences on OT clinical reasoning. These include the therapy context, the client situation, theory, the identity of the therapist, attitudes about therapy and expectancies of OT outcomes. These influences affect decision making and address the question ‘what do therapists think about’ when they reason.

The Therapy Context The context of therapy contains powerful factors that establish knowledge about the conditions (e.g., organizational, cultural and societal values) and constraints (e.g., human and financial resources, policies) that affect therapy (Kristensen et al., 2012). Therapy experiences are remembered by therapists as total contextual patterns of what is possible and include people, actions, contexts and objects, rather than as decontextualized elements or general rules (Schell and Schell, 2008). Contextual patterns contribute to therapists’ perceptions of the amount of control they have over their ability to carry out planned actions. These perceptions have a direct effect on their feelings of efficacy, selfconfidence and autonomy (Sharafaroodi et al., 2014). Therapists reason according to both personal values and professional perspectives. If the therapy context does not permit these values

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and perspectives, then therapists face a dilemma. There is a conflict between what therapists perceive should be done, what the client wants done and what the system will allow. These constraints can impose major restrictions on clinical reasoning.

Clients and Their Life Contexts Sensitivity to clients and their life situation is fundamental to the clinical reasoning process. A core ethical tenet of OT is that interventions should be in concert with clients’ needs, goals, lifestyles and personal and cultural values (Chapparo et al., 2017a). To this end, Mattingly and Fleming (1994) originally described one of the primary goals of clinical reasoning as determining the meaning of occupational need from the client's perspective. Understanding of the client's perspective becomes a source of knowledge that is used during assessment and intervention and is constantly updated to build a conceptual model of the client situation (Mattingly and Fleming, 1994; Schell and Schell, 2008) (Box 25.2).

Box 25.2

Types of Knowledge Contributing to Understanding of the Client's Occupational Need ■ Knowledge of the client's motivations, desires and tolerances ■ Knowledge of the context within which occupational performance occurs ■ Knowledge of the client's abilities and deficits ■ Insight into the existing relationship with the client, its tacit rules and boundaries ■ Predictive knowledge of the client's potential in the long term

Theory and Science Therapists’ knowledge about disease, human function and human

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occupation, gleaned largely from scientific theory and evidence gives direction for thinking, information about alternatives and predictions of function. Termed ‘professional knowledge’, it is conceptualized as applied theory when used in a process of ‘naming’ and ‘framing’ the problem (Kielhofner, 2009). This process requires classifying findings in terms of abstract constructs (such as function, depression, sensory processing, motor control, occupational role, cognitive ability or social justice). The identified construct becomes a cognitive mechanism that facilitates the selection of strategies for assessment and treatment (Schell and Schell, 2008). However, OT has a theory base that is incomplete and is characterized by philosophical conflict. Additionally, therapists are required to make decisions in situations of uncertainty that stem from multiple sources or for which there is little evidence. Under these conditions, therapists may have to use their own personal beliefs and experience as a basis for decision making.

Personal Beliefs of the Therapist The fourth type of knowledge that guides reasoning is personal knowledge incorporating the beliefs and values of the therapist. These are the fundamental beliefs and assumptions about what we know ‘to be true’ about ourselves, others and OT. Therapists use themselves as referents when creating a model of the client situation (Chapparo, 1999), ascribing meaning to the client's individual situation according to his or her own reality. Therapists probably develop an internal model of what they believe is the client's perspective and work from that belief model. Such beliefs and values are used to define the limits of acceptable behaviour in any given therapy situation (Chapparo, 1999).

Attitude-Behaviour Expectancy Scheffer and Rubenfeld (2000) suggest that attitude, philosophical perspective and beliefs set up a thinking ‘disposition’ that influences the clinical reasoning process. Attitude-behaviour theory has been used to demonstrate the effect of attitude on OT reasoning (Chapparo, 1999). This model proposes therapy is mediated through intention (what therapists choose to do) and expectancies

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(the perceived expectations of self and others). Attitude (seen here as what therapists imagine as positive or negative outcomes of therapy possibilities) develops from sets of beliefs derived from the personal, theoretical and contextual knowledge outlined earlier in the chapter. This conceptual model of reasoning is an explanation of the effects of attitude on clinical reasoning. Attitudes of therapists about their therapy can be triggered by specific and changing events in therapy and contribute to the development of an internal frame of reference about the processes they choose to use during therapy.

Personal Internal Frame of Reference The existence of a personal paradigm (Creek and Lawson-Porter, 2007) is believed to underlie all decisions made in professional practice. Clearly, clinical reasoning in OT balances a number of personal, client-related, theoretical and organizational sets of knowledge. How therapists determine which type of knowledge receives precedence in reasoning for each individual therapy situation is not yet clear. One emerging hypothesis is that all sources of knowledge used for clinical reasoning are housed within a complex internal framework structure that has precognitive and cognitive elements that represent the therapist's personally constructed view of any therapy event (Chapparo, 1999) and affect clinical reasoning (Fig. 25.1).

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The therapist internal personal reference system. A personal knowledge structure that is shaped by beliefs, attitudes and expectations. Therapy (action) is preceded by an intention to act in a particular way (therapy plan). Intentions are shaped by attitudes towards the salient therapy situation. Attitudes are shaped by a constellation of beliefs about aspects of the therapy situation.

FIG. 25.1

Lines of Reasoning In the third section of this chapter, we explore the ways in which therapists use different lines of thinking to form pictures of client problems, client potential, therapy action and outcome. We address the question “how do therapists use their knowledge during clinical reasoning?” The majority of this information has been derived from what has been considered the keystone study into clinical reasoning in OT (Mattingly and Fleming, 1994). Although a relatively small, culturally and geographically localized study with inherent biases, it exerts disproportional influence on how clinical reasoning in OT is described and taught today.

Scientific Reasoning: “What Is the Presenting Problem?” Two forms of scientific reasoning identified by early OT researchers are diagnostic reasoning and procedural reasoning (Mattingly and Fleming, 1994). These processes involve a progression from

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problem sensing to problem definition and problem resolution. This line of reasoning is the “how to” of the therapeutic process. The focus is on the problem, and therapists draw on their knowledge of occupations, therapy procedures, diseases and conditions to address it. Problem identification, goal setting and intervention planning are part of these diagnostic and procedural reasoning modes. Therapists generate two to four hypotheses about the cause and nature of functional problems and several more concerning possible directions for treatment (Mattingly and Fleming, 1994) (see Case Study 25.1). Hypotheses are then subjected to a process of critical reflection and consideration of evidence. Newer therapists tend to generate fewer hypotheses (Unsworth, 2011). The danger for experienced therapists is placing exclusive dependence on past experiences that have not been subjected to critical analysis through evidentiary inquiry.

Case Study 25.1

Brief Example of How Some Narrative and Scientific Lines of Reasoning Contribute to Generating Hypotheses About the Nature and Cause of the Occupational Problem Danny is 4 years of age and was referred to OT early-intervention services. Julia is his therapist and is experienced in earlyintervention service delivery. Julia observes that Danny notices toys and picks them up now and then. During mealtime he uses his left hand to pick up his food to eat but seems more interested in the touch and feel of it, often throwing it on the floor. Although he is aware of his family, his social responses are inconsistent. He often appears ‘distant’ and ‘anxious’ when family members leave the room.

Scientific Reasoning Julia further constructs a picture of the problem from evidence about Danny's diagnosis and her knowledge of typical and atypical childhood social and occupational performance. Medical: Danny has reduced motor control on his right body

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side in comparison with the left and was given a diagnosis of cerebral palsy (unilateral) and developmental delay. Social/Occupational: Delayed ability to interact with other children, reduced potential to play with toys and others and reduced independence in eating and drinking often result from these conditions.

Narrative Reasoning Julia further constructs a picture of Danny's occupational life by talking to his family to obtain their perspective of the problem and what they expect from therapy services. As a result of an abusive early childhood for the first 3 years of life, Danny was placed with foster parents who have two other children younger than 5 years of age. He has received no previous intervention. He attends a day-care facility 3 days a week for 7 to 8 hours each day with his foster siblings. There are positive reports about the day-care providers. Danny has made progress since being fostered. The family would like Danny to: ■ use a cup and feed himself without throwing food, ■ develop more play skills and engage in social interaction, ■ use his right hand and arm and ■ have a regular sleep/wake schedule. Hypotheses About Danny's Situation Generated From Scientific and Narrative Reasoning Julia uses this information to generate the following hypotheses: The underlying causes of the child and family's identified needs, concerns or problems are as follows: ■ Danny's problems are linked to his early developmental experiences. ■ Danny has not had the physical, social and sensory opportunities that prompt early skill development and will need to spend time experiencing these. ■ He has experienced less social attachment and interactions than needed to develop play and social-emotional skills, and foster parents may need some support in the best ways to

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develop these. ■ Danny may not have had parent-supported routines and schedules to develop sleep patterns, social interactions and eating routines in early infancy and needs to learn these. ■ Danny may have needed early intervention services to address the effect of reduced developmental opportunities and did not receive these.

Narrative and Interactive Reasoning: “What Does It Mean to the Person?” Implementing a therapy program that will potentially change life roles and functions for the client requires understanding the meaning of a client situation. Two dimensions of meaning making are involved and have been referred to as narrative and interactive reasoning. Meaning perspectives are the assumptions and beliefs within which new experiences are interpreted. For example, OTs make interpretations about client situations based on perceived client satisfaction with occupational roles and tasks, interpretation of client past life experiences and future desires. Therapists construct perspectives of the client experience into a personal narrative or a story of the situation in a way that parallels the hermeneutic process (Chapparo, 2016). The therapist's views of the situation become gradually ‘fused’ with the client's until the client's experience, rather than the problem per se, becomes paramount (Mattingly and Fleming, 1994). This interpretive process prompts decisions about therapy action (or nonaction) (see Case Study 25.1).

Ethical Reasoning: “What Should Happen?” As outlined previously, personal values substantially affect clinical reasoning processes in OT. A therapist–client interaction becomes an ethical dilemma when it seems that an OT treatment decision will violate the therapist's values. In the process of choosing a therapeutic action, occupational therapists are often forced to balance one value against another. Although this process is typically unconscious, it can drive decision making at any point in the therapist–client interaction (Jordens and Little, 2004) (Box 25.3).

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Box 25.3

Therapists Are Strategic Thinkers Being a strategic thinker presupposes that therapists simultaneously know what has to be accomplished (goal) and can make plans (planning), initiate strategic behaviour (initiation), pay attention to their own and the client's performance (monitor) and evaluate their thinking and resulting actions in relation to the goals (reflection, self-evaluation and situation evaluation).

Conditional Reasoning: “What Will Be the Outcome?” Mattingly and Fleming (1994) described a line of reasoning termed ‘conditional reasoning’, which involves projecting an imagined future for the client. They used the term ‘conditional’ in three different ways. First, problems are interpreted and solutions are realized in relation to people within their particular context. Second, therapists imagine how the present situation could be changed. Third, success is determined by the level of client participation and satisfaction. It is a line of thinking used to reconcile the actual (therapy) and the possible (intention) in terms of therapy outcome. This involves reflection, when the therapist's action turns in on itself, conflict, when therapists seek to reconcile choices made, and judgement, when therapists weigh soundness of decisions.

Pragmatic Reasoning: “What Can Be Done?” Pragmatic reasoning addresses what is achievable in the contexts in which therapy occurs (Schell and Schell, 2008). As outlined earlier in the chapter, this includes organizational constraints, values and resources, practice trends, reimbursement issues and therapist skills. Evans (2010), for example, highlights the place of social influence and conformity to the expectations of colleagues. Curtin and Jaramazovi (2001) demonstrated how, despite a positive disposition towards evidence-based practice, therapists cite lack of skills and resources as barriers to inclusion of evidence in their reasoning. Famously, Mattingly and Fleming (1994) created an image of an

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occupational therapist with a ‘three-track mind’ (p. 119). Tracks are lines of thinking that are related to thought content rather than describing how thinking happens. All lines of reasoning may be used in one therapy session. The procedural track is used when therapists reason about the client's diagnosis. The interactivenarrative track occurs when therapists focus on the client as a person. The conditional track creates an image of the client that is provisional, holistic and conditional on the client's participation. The line of thinking used at any time during therapy is related to the salient goal of therapy (e.g., determining occupational diagnosis, exploring alternatives with clients, setting short-term goals, evaluating intervention, discharge planning).

Reflection Point 2 It is unclear whether therapists use exclusive forms of thinking or whether the different styles of reasoning that have been identified in each piece of research were constructed through the research process of attempting to describe in words a largely internal, tacit phenomenon (Robertson, 2012). Therapists may seem more rational in their decision making when interviewed after the fact because of the coherence that comes with reflection and the rules of narration. Descriptions of the different clinical reasoning processes that exist may reflect the epistemology of various researchers at the time (Robertson, 2012), such as anthropology (Mattingly and Fleming, 1994), medicine, cognitive psychology (Chapparo and Ranka, 2016) and social psychology (Chapparo, 1999; Unsworth, 2011).

Information Processing, Cognitive Strategy Use and Clinical Reasoning It has been argued that conceptualizations of clinical reasoning within the profession have not kept pace with cognitive research about thinking and reasoning (Robertson, 2012). Here we address the question “how do therapists think?” Kahneman (2011) proposes two distinct cognitive systems

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underpinning reasoning. System 1 operates automatically and quickly, with little or no effort or control, and is sensory dependent. For example, as we talk to a client, we automatically alert to their facial expression of pain, or reposition equipment, without conscious thought. System 2 comprises complex effortful deliberate thinking. How this type of cognition is applied in OT reasoning is just beginning to be explored (Pelaccia et al., 2011). Next, we briefly describe a recent model of cognitive strategy use that incorporates this dual-process paradigm. Clinical reasoning in OT requires therapists to extend their thinking beyond what they know and beyond the context in which they do therapy (Carr and Shotwell, 2007). In many instances, OT requires therapists to ‘know the unknown’. At the same time, therapists must access and use some knowledge so automatically that they can ‘do without thinking’, for example, be able to think ahead to the next sequence of a therapy session while automatically positioning a client or themselves safely for a wheelchair transfer. Of particular relevance is how therapists might use a range of cognitive strategies during everyday reasoning to achieve the best outcome for clients. Cognition has been defined many ways. In this chapter, it is defined as an interaction of processes that involve all forms of awareness and knowing such as sensing, remembering, questioning, judging, problem solving and decision making (VandenBos, 2015) and subsumes metacognition (thinking about one's own thinking). Cognitive strategies are mental thinking tactics, or how we use our cognition. They are used when we are faced with the need to identify important, unfamiliar or difficult information; understand and retain information; retrieve information from memory stores; manipulate and apply information; plan and modify responses using information; and simultaneously cope with internal and external distractions during task performance (Ramsden, 2013). Cognitive strategy use is dependent on information processing. This processing system is controlled by an executive system that monitors thinking processes and engages in corrective strategies when processing is not going smoothly (Huitt, 2003). Central to applying notions of cognitive strategy use to clinical reasoning is the assumption that successful reasoning requires both automatic (System 1) and deliberate use of information (System 2) processed

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through application of a set of cognitive strategies that suit each situation. During clinical reasoning, therapists gather information from people, things and events in their environment (using sensory gathering strategies). They organize this information in their minds and code it in ways that keep it usable and easily understood (memory storing strategies). They match the sensory information with what they have learned and experienced, noticing similarities and differences and store the information for future use (recall strategies). As these representations of therapy become deeper and more powerful with repetition over time, therapists’ understanding of client problems, worldviews and therapy outcomes becomes more precise, and they are able to apply their knowledge using a range of cognitive strategies across a wide range of clients and therapeutic tasks (generalizing, planning, decision making and selfevaluating strategies). They become strategic thinkers, using internally generated cognitive strategies. Cognitive strategies can be classified as general (generic thinking strategies that are applied to any task) or more specific (strategies that relate to a particular task, such as a specific way to use particular equipment) (Chapparo, 2017). Each therapy session demands particular client information to be chosen, constructed, processed, stored, recalled, organized and used for a particular therapy purpose. Cognitive strategy use implies salience or use of a general set of cognitive strategies in a particular moment. Chapparo et al. (2017b) hypothesize that people do not use ‘different’ lines of thinking for clinical reasoning but rather learn to apply a generic set of thinking strategies that they already use in daily life to a specific situation. Although therapists develop particular and specialized knowledge structures about occupation, disability and therapy, they learn to apply or manipulate this knowledge to problems of occupation in their role as a therapist using an already existing generic set of thinking strategies. Perhaps this is what is meant by learning to ‘think like a therapist’. Chapparo et al. (2017b) constructed a conceptual model of how people use cognitive strategies during task performance. Termed the Perceive, Recall, Plan and Perform (PRPP) system (Fig. 25.2), it is centred on four processing ‘quadrants’ connected by multidirectional arrows that mirror the four-staged flow of information in theoretical models of information processing. These

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quadrants include attention and sensory perception (Perceive), memory (Recall), response planning and evaluation (Plan) and performance monitoring (Perform). Built on earlier notions from instructional psychology (Romiszowski, 1984) and applied cognitive task analysis (Schraagen et al., 2000), it has been used to explain people's ability to use cognitive strategies to effectively think through routine and complex work tasks (Bootes and Chapparo, 2010; Lewis et al., 2016). Here, we apply this model to therapist thinking.

FIG. 25.2 The Perceive, Recall, Plan and Perform

(PRPP) System of Task Analysis Conceptual Model: Hypothesized Cognitive Strategies Used in Clinical Reasoning During Every Therapy Situation.

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Perceive Strategies: Attention and Sensory Perception Strategies (Strategies for Attending to and Sensing Information) Once sensory input from a client or therapy context captures our attention, and we focus on it, details of the information are registered. Initial interpretation of sensory data is thought to precede conscious thinking, suggesting that client and contextual information is always interpreted preconsciously in the first instance (Hogarth, 2005), mirroring the System 1 concept outlined earlier in the chapter. The more attention we pay to a given bit of sensory information (e.g., a painful wrist joint or listening to a client narrative), the more elaborately the information will be learned and retained. The top-left quadrant (Perceive) in Fig. 25.2 outlines some specific cognitive strategies from the PRPP system associated with this first stage of information processing. These strategies are observable behaviours that signal whether therapists are attending to and dealing with sensory input that is needed for therapy (Chapparo and Ranka, 2016).

Recall Strategies (Strategies to ‘Know’ and Use What Is Known) Sensory images of people, things and contexts are transferred to a working memory, which is what we are thinking about at any given time. Memories of our personal, client and therapy experiences are then configured into long-term memory structures called ‘schemas.’ Schemas serve as filters for ongoing experience, allowing us to come to conclusions about what we see, hear or do automatically (Hattie and Yates, 2014) without having to ‘think too hard’ and is often referred to as ‘automaticity’ (Chapparo, 2017). This line of thinking is depicted by arrows from Perceive to Recall to Perform in the central part of Fig. 25.2. During clinical reasoning, this enables us to interpret the present based on experience from the past and answer the question “Do I know…?” (Chapparo and Ranka, 2016). Three broad categories of information are stored and retrieved for use during clinical reasoning. These are explained in the following sections.

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Factual Knowledge (Facts) –‘Do I Know WHAT…?’ The storing and recalling of facts enable therapists to recognize sensory data from clients and situations and the meaning that is attached to them. It makes a major contribution to practical knowledge and is the basis for diagnostic and procedural reasoning. Sensory images are assigned technical labels that assist with efficient storage and retrieval. Labels such as pain, depression and stroke become fused with our own personal understanding of these terms and are used to assign meaning to client and therapy events. This builds the ‘internal frame of reference’ outlined previously and becomes the sum total of what we know about ourselves and others and is probably used during what has been termed ‘narrative’ or ‘interactive’ reasoning.

Schematic Knowledge (Schemes) –‘Do I Know WHERE…?’; ‘Do I Know WHEN…?’; ‘Do I Know HOW LONG…?’ Schematic memory represents what we have learned about where, when and how long something happens. This type of memory is based on particular experiences that are located in personal time and space and may contribute to pragmatic reasoning. Schematic information provides us with a personally constructed ‘map’ or model for when and where to act as a therapist.

Procedural Knowledge – ‘Do I Know HOW…?’ Procedural memory enables us to perform therapeutic techniques ‘automatically’ based on past experience. Procedural memory has been shown to be the most resistant to forgetting and foremost in the natural inclination for therapists to ‘do what they know’ in the first instance. Experienced therapists often seem to ‘do therapy’ without thinking because they have highly developed procedural knowledge. Therapists moving from one specialized practice to another will have to develop new procedural knowledge. The top-right quadrant (Recall) in Fig. 25.2 outlines some specific cognitive strategies from the PRPP system associated with this second stage of information processing.

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Plan Strategies (Strategies to Map Out, Program and Evaluate Future Action) Organization, problem solving, decision making and insight are all part of the third stage of information processing and can be thought of as the ‘rules of operation’ that we apply to problem solving and analyzing information in any situation that is novel or complex. Planning strategies are not linked to any particular type of sensory information or ability but are executive functions that are applied to all information that has to be organized for use in a particular way or when what we know is not enough. When reasoning through complex therapy events, we process information with reference to a particular goal, an idea or an understanding of an outcome (what will happen?). With an outcome in mind, effective thinkers use cognitive strategies that enable them to put a therapy plan into action. Although knowledge is used as a platform for this aspect of reasoning (arrow from Recall to Plan, see Fig. 25.2), planning strategies are different from the recall strategies described earlier and involve ‘figuring out’ extensions to habitual responses that may be demanded by the client situation. This can involve rapid searches for additional information to solve a problem (arrow from Plan to Perceive, see Fig. 25.2). Effective clinical reasoning happens when therapists reflect on their own plans and performance and make considered decisions (Kieran and Christoff, 2014). Some of the cognitive strategies involved in the planning aspect of information processing during clinical reasoning are listed in the lower-right quadrant in Fig. 25.2 (Plan).

Reflection Point 3 Problem solving is paramount when planning around complexity or novelty and is stimulated by the following self-generated questions: • What obstacles might/did get in the way? • How can I get myself and the client ready for therapy? • What is the best choice of therapy approach, place and tool to

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use for this specific therapy task? • How do I have to sequence therapy? • What do I have to do to make my responses fit the client expectation/therapy context/my abilities? • What personal reactions to client and therapy events do I have to consciously inhibit?

Perform Strategies (Strategies Used to Time, Control and Monitor Therapy) After planning, the last stage of information processing focusses on using thinking strategies to ‘do’ therapy (arrow from Plan to Perform, see Fig. 25.2). New information requires therapists to dynamically respond ‘in the moment’. Therapists’ own actions are fed back into the system as sensory input and result in not only remembering what has been done and how (arrows from Perform to Perceive, Perform to Recall, see Fig. 25.2) but also the thinking that preceded it (arrow from Perform to Plan, see Fig. 25.2). For this attending, sensing, knowing, thinking, doing system to be effective, therapists must have a firm outcome (goal) in mind and be able to bring the goal back into focus for review as they do therapy.

Chapter Summary Clinical reasoning in OT is based on the complex interaction between people and their environments as they perform relevant and valued everyday activity. As contemporary therapy becomes increasingly aligned with community service delivery systems in public health, social welfare and education, there are suggestions for ‘clinical’ reasoning to be termed ‘professional’ reasoning. There is general agreement that:

■ There are multiple lines of reasoning in OT, providing a multifaceted view of clients’ problems, capacities, futures and therapy outcomes. Ethics and pragmatics further frame our views of clinical reasoning. 629

■ Each therapist constructs a personal internal frame of reference, in which information about clients and the client situation are thought to be ‘fused’ with the therapist's personal beliefs about such things as perceived level of skill, ethics and perceived level of control. Such images serve to make clinical reasoning an intensely personal process. ■ From a cognitive perspective, clinical reasoning is thought to be served by a dual-process system that is part automatic use of professional and personal knowledge and part deliberate thinking. Reasoning is carried out through application of multiple cognitive strategies that are applied in the moment to suit the goal of therapy. Reflection Point 4 Current explanations of clinical reasoning in OT are continually evolving. It is a highly individualistic mode of social interaction that is informed by scientific knowledge and method, creative imagination, intuition and interpersonal skill and that uses an attending, sensing, knowing, thinking, doing cognitive system that operates strategically within the frame of the OT profession.

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26

Clinical Decision Making in Emergency Medicine Pat Croskerry

CHAPTER AIMS The aims of this chapter are to: ■ review the recent emergence of clinical decision making in the context of patient safety, ■ emphasize the critical role of rationality in clinical decision making, ■ review the main facilitators of rationality, ■ examine the components of dysrationalia and ■ outline some of the special characteristics of clinical decision making in emergency medicine.

KEY WORDS Patient safety

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Dual-process theory Emergency medicine Mindware Cognitive bias

ABBREVIATIONS/ACRONYMS CDM Clinical decision making IOM Institute of Medicine ED Emergency department EP Emergency physician

Introduction Several decades ago, it could have been reasonably said that the average emergency physician (EP) did not give a lot of thought to his or her decision making. For most, clinical decision making (CDM) was largely a reactive process. Patients came to the emergency department (ED) with various symptoms and signs, were diagnosed, treated and either admitted or discharged. Clinical reasoning and decision making were embedded somewhere in the process, but it was rarely if ever thought about in any depth and certainly did not merit much discussion in the literature. David Eddy, one of the pioneers of evidence-based medicine, noted that in the 1970s: ‘Medical decision making as a field worthy of study did not exist’ (Eddy, 2005, pp. 9–17). However, since the turn of the century, two major developments have taken place that have significantly affected the way we look at decision making in emergency medicine: the development of the patient safety movement and the incorporation of the cognitive science approach to decision making into mainstream medicine and emergency medicine.

Reflection Point 1 The current emphasis on clinical decision making can be seen as a

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confluence of developments in patient safety and cognitive science. The patient safety movement gathered momentum through the last part of the 20th century but was galvanized by the US Institute of Medicine (IOM) report To Err Is Human (Kohn et al., 1999). Described as ‘the shot heard around the world’, the report became the tipping point for a whole new approach to patient safety. Following general overviews of the topic (Aspden et al., 2004; Vincent, 2006), several disciplines produced their own specialized treatments, including emergency medicine (Croskerry et al., 2009), in which CDM received considerable attention. It was clear that CDM was an important, if not dominant, aspect of patient safety, although this had not been fully appreciated in the IOM report. Wachter (2010) noted that whereas medication error was mentioned 70 times, diagnostic error (often the outcome of poor CDM) was mentioned only twice (p. 1605). This omission was corrected in 2015, when the former IOM (now the National Academies of Sciences, Engineering, and Medicine) published Improving Diagnosis in Health Care (Balogh et al., 2015). An important chapter in the book was devoted to the diagnostic process, which included a review of clinical reasoning and decision making. From a relatively obscure position, CDM was now catapulted to the forefront. The second major development was the cognitive revolution in psychology and the emergence of the ‘heuristics and biases’ literature. This began in the 1970s with the publication of several papers that were the harbinger of hundreds of others to follow over the next 40 years (e.g., Kahneman, 2013). Collectively, they demonstrated that human reasoning and decision making, at times, are significantly compromised. Systemic irregularities in human cognition were widespread. The ultimate focus of this failure was on the rationality of the decision maker, a characteristic that is extremely important in the makeup of the emergency physician.

Emergence of Dual-Process Theory in Clinical Decision Making Before discussing rationality, it would be helpful to look at how the brain actually makes decisions. The dominant model has been dual-

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process theory, which has been widely incorporated into decision making in multiple fields of human activity, including medical decision making (Croskerry 2009). Fig. 26.1 shows a schematic adapted from that paper. It is now widely taught and forms the basis of a recently published educational module on cognitive error and debiasing in emergency medicine (Daniel et al., 2017). Dualprocess theory proposes two ways in which we make decisions. These have been termed System 1 or Type 1 processing (intuitive), which is typically automatic, autonomous, fast, nonverbal and often driven by pattern recognition, and System 2 or Type 2 processing (analytical), which is slow, deliberate, verbal and generally less prone to error (Croskerry, 2009). In Fig. 26.1, the two dotted-line boxes leading into each system contain proposed determinants, respectively, of the two systems.

FIG. 26.1 Dual-process model of clinical decision making. (Adapted from Croskerry, P., 2009. A universal model of diagnostic reasoning. Acad. Med. 84, 1022–1028, with permission.)

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Reflection Point 2 Dual-process theory is the dominant model for characterizing the two systems of decision making: intuitive (System 1) and analytical (System 2) processing. The model runs from left to right. The patient presents with symptoms or signs that may form a pattern that is immediately recognized (e.g., the rash of shingles), and the diagnosis can be made in fractions of a second. The four major channels of Type 1 processing, not elaborated upon here, are described in more detail elsewhere (Croskerry et al., 2013). Most biases reside in System 1. If the pattern is not recognized, Type 2 processing is required and is enacted deliberately through a single channel, which, typically, may take considerably longer. Repetitive Type 2 processing can lead to Type 1 processing, in the acquisition of a skill such as intubation. System 2 may exert executive override of the output from System 1 – this decoupling is at the basis of reflection, metacognition and mindfulness and provides the means for cognitive bias mitigation. System 1 can also override System 2, such that despite knowing the most rational thing to do, intuitive responses can preponderate. This is referred to as dysrationalia. In the model, T represents a toggle function, the ability to move back and forth between the two systems. Overall, there is a tendency to default to System 1, where less cognitive effort is required – referred to as cognitive miserliness. We spend most of our time in System 1.

Rationality in Clinical Decision Making Normative decision making is characterized as the best possible decision by ideal decision makers who are able to compute with high degrees of accuracy and rationality with sufficient resources at their disposal. It is clear, however, that this normative ideal is often not reached. Over the past 40 years, cognitive science has unequivocally established the general vulnerability of human

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decision making. Extensive nonnormative decision failures have been described. There are significant individual differences that affect decision making (Croskerry, 2017a) and, therefore, substantial variation. Thus just like intelligence, human rationality is normatively distributed. Generally, it is optimal when the decision maker is knowledgeable about the topic, has the intellectual capacity to think at the level of complexity the task demands, demonstrates critical thinking skills and has favourable individual characteristics (e.g., mindfulness, metacognitive awareness, actively open-minded thinking and others) as illustrated in Fig. 26.2 (Croskerry, 2017b).

FIG. 26.2 Major components of rationality. (Croskerry, P. 2017b. The rational diagnostician. In: Croskerry, P., Cosby, K.C., Graber, M.L., Singh, H. (Eds.), Diagnosis: Interpreting the Shadows. CRC Press, Boca Raton, FL, forthcoming, with permission.)

Reflection Point 3 Rationality is the quintessential characteristic of a good decision maker in emergency medicine.

Facilitators of Rationality For optimal rationality, there need to be sufficient facilitators (Fig. 26.3) and minimal inhibitors (see Fig. 26.4). Facilitators are cognitive

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components that support and promote rationality. The dual-process model provides a good conceptual scaffold for thinking about decision making. In particular, it illustrates the important capability of decoupling from System 1 and using System 2 to modulate decision making. This is accomplished, for example, through the basic processes of metacognition, reflection and mindfulness. An awareness of cognitive biases and logical fallacies, and how they work, is also important. Having identified bias in one's decision making, the capacity to apply cognitive bias mitigation techniques (mindware) may be necessary to deal with them. Being able to reflect upon one's reasoning and decision making is important because it allows a second look at what has been done or is about to be done. Similarly, mindfulness is the ability to apply attitudinal qualities that may improve thinking, such as patience, beginner's mind, trust, nonjudging, nonstriving, acceptance and letting go, originally described by Kabat-Zinn (1990). These qualities of mind can be used to mitigate some well-known cognitive biases (Sibinga and Wu, 2010). Further, although a number of individual faculties are associated with optimal decision making (Croskerry, 2017a), chief among them are those that support Actively Open-Minded Thinking (AOT), a personality trait that correlates highly with rationality (Baron, 1993; Stanovich et al., 2016). Other cognitive faculties that avoid cognitive miserliness, such as perseverance, effortful thinking and conscientiousness, also support rationality.

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FIG. 26.3 Individual facilitators of rationality.

FIG. 26.4 Components of dysrationalia.

Dysrationalia Inhibitors of rationality lead to dysrationalia, defined as ‘the inability to think and behave rationally despite having adequate intelligence’ (Stanovich, 2009a, p. 35). These can be divided into process and

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content problems (Fig. 26.4) (Stanovich, 2009b). An important processing problem is cognitive miserliness. Although we do not have a deliberate strategy not to use our brains, we are inclined to engage thinking that is fast and computationally inexpensive. Such cognitive miserliness is often the best strategy in emergency medicine – we often rely on not overthinking issues that can be reliably dealt with quickly. Thus cognitive thriftiness often serves us well, but occasionally it may result in missing the correct solution. Fig. 26.5 illustrates a problem originally attributed to Bob Moore (Levesque 1986, p. 85). In Fig. 26.5, we are given four true statements and asked the question: Is a married person looking at an unmarried person? About 80% of people will say the answer cannot be determined (Stanovich, 2009b). Because Ann's marital status is unknown, they choose not to pursue the search for a solution and leave it there. The problem appears insoluble, and no further effort is made. However, with a little perseverance some people realize that because Ann has only two states, married and unmarried, they can compute the correct answer by considering each separately. If Ann is married, the answer is yes because she is looking at George who is unmarried. If Ann is unmarried, then the answer is still yes because Jack is looking at her. Whether she is married or not, the answer is yes. Thus the correct solution is available with a little extra cognitive effort, involving disjunctive reasoning.

FIG. 26.5 Cognitive miserliness.

Consider now the clinical example in Case Study 26.1. There are several biases that contribute to the correct diagnosis not being made in a timely fashion at the first visit. The patient is well known

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for being a frequent visitor to the ED. Physicians who see her experience a sense of futility that they will ever find a diagnosis to explain her symptoms given she has been seen by numerous specialists in the past. This is an example of the Yin-Yang Out bias – the patient has been ‘worked up the Yin-Yang’ with no firm diagnosis, therefore, further efforts are probably futile. Unfortunately, she has acquired the pejorative label of ‘frequent flyer’, which means she is perceived as inappropriately using the ED. Also, she has the psychiatric diagnosis of somatic symptom disorder, which may manifest in several ways; in this case, it appears to be illness anxiety disorder. One of the Psych-Out biases is to ascribe somatic symptoms to a psychiatric condition rather than evaluate them objectively. The EP is also fatigued, and the department is very busy, and he fails to muster sufficient reserve to complete a more thorough evaluation. This is an example of cognitive miserliness associated with significant contributory factors (decision fatigue, general fatigue, possible dysphoria from fatigue and/or the pressures from overcrowding and likelihood of minimal yield for cognitive effort).

Reflection Point 4 Cognitive miserliness allows EPs to deal with many routine decisions in the ED using minimal effort, but occasionally miserliness may lead to significant difficulties.

Case Study 26.1

Stacey (a Frequent Visitor to the Emergency Department) Stacey is a 28-year-old patient who presents to the emergency department (ED) with lower abdominal pain. She has had numerous visits to the ED over the past few years with similar complaints and is known to have visited all four EDs in the city in the same evening. She is described as a ‘frequent flyer’. She has been extensively investigated by gynaecology, urology, gastroenterology and psychiatry. Despite numerous investigations

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including ultrasound, abdominal CT and hysterosalpingogram, no somatic cause has been found for her discomfort. The ED is extremely busy with 30 people in the waiting room. The EP who assesses her has seen her several times in the past. Her abdominal discomfort is mostly on the left side. Her vital signs are stable. She has a soft abdomen with good bowel sounds and vague tenderness in the left lower quadrant. Her urinalysis is normal. The EP reassures her that she doesn't have a urinary tract infection and does not appear to have any serious condition. He comments on the extensive workups she has had in the past for similar symptoms. She tells him that she feels different this time, but he reminds her that she has said that numerous times before. She responds well to further reassurance, and he discharges her from the ED. The next afternoon, she is brought back to the same ED having collapsed at the local mall. She is pale and hypotensive. Bloodwork shows a haemoglobin of 6 and a positive pregnancy test. Pelvic ultrasound revealed a complex adnexal mass on the left side with a large amount of free fluid. She is diagnosed with a ruptured ectopic pregnancy and taken immediately to the operating room. Comment. The EP was aware of the patient's label as a ‘frequent flyer’ and her diagnosis of somatoform disorder and well aware of the perils of making assumptions about such patients. However, he saw her in the closing hours of an 8-hour shift in a very busy ED and was fatigued. Had he simply allowed the patient the benefit of the doubt and performed a pregnancy test on the first visit, he may well have made the correct diagnosis. The other major factors that contribute to dysrationalia are content problems (see Fig. 26.4). These are divided into mindware gaps and mindware contamination. Simple knowledge deficits, such as not knowing that knee pain may be a manifestation of a hip problem in children or that hypoglycaemia may mimic almost any neurological condition, or indeed medical knowledge generally, may certainly cause problems for clinical reasoning, but such medical knowledge deficits can be distinguished from mindware gaps, which are specific deficiencies in knowledge about reasoning. Stanovich and West cite numerous studies demonstrating such failings:

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people's responses sometimes deviate from the performance considered normative on many reasoning tasks. For example, people assess probabilities incorrectly, they test hypotheses inefficiently, they violate the axioms of utility theory, they do not properly calibrate degrees of belief, their choices are affected by irrelevant context, they ignore the alternative hypothesis when evaluating data, and they display numerous other information processing biases (2000, p. 645). Common examples of mindware gaps are poor probabilistic reasoning, fallacies in logical reasoning and impaired scientific reasoning. Much of this mindware content knowledge is taught in medical undergraduate courses on clinical epidemiology and biostatistics and is well covered in textbooks (Weingart and Wyer, 2006; Rao, 2007). Students are taught about test specificity, sensitivity, likelihood ratios, Bayesian reasoning, number needed to treat and other bio-statistical tests that will enable them to critically evaluate tests and studies published in the literature. Most EPs will have had the benefits of such training. However, this knowledge and the skills necessary to apply it will fade unless it becomes a routine of practice, so there is an imperative to reinforce it in practicing EPs. In emergency medicine, excellent coverage of potential mindware gaps together with a strong dose of critical thinking and evidence-based medicine is provided in a book by Weingart and Wyer (2006). Many of the clinical examples given by Gigerenzer in a chapter on physicians' decision making titled ‘What doctors need to know’ are mindware gaps of this type (2014, pp. 159–186). Problems with probability reasoning are illustrated in Case Study 26.2. The nurse first recognizes the pattern of leg pain and chest pain, which are consistent with pulmonary embolus (PE) and, especially in view of her recent experience with two cases of PE (availability bias), orders a D-dimer test. The test is sensitive but has very low specificity, which means that it is good for ruling out deep venous clots and PE but not good at ruling them in. In this case, given the very low pretest probability that the patient has this diagnosis, the test should not have been ordered. Elevated levels may be caused by recent surgery, trauma, infection and some other conditions. Minor elevations above the cutoff value are not

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uncommon. Once the test has been done, however, and yields a positive result, there is an onus on the physician to explain it. The physician failed to stick with the original judgement and agreed to an unnecessary test thus exposing the patient to unnecessary radiation.

Case Study 26.2

Brad (Worried About His Heart) Brad, a 32-year-old male patient, comes to the ED with pleuritic chest pain and feeling slightly short of breath. He is very anxious. He is concerned he may be having a heart attack. His brother-inlaw had similar symptoms 1 week ago and is currently in the cardiac care unit (CCU). His vital signs are stable at triage other than a slightly elevated respiratory rate (22) and tachycardia (110). He is triaged to the cardiac room. The ED is busy. Routine bloodwork is done, including cardiac enzymes, and a cardiogram and chest x-ray are ordered. He is assessed by the EP after about 20 minutes. Brad's wife is with him and appears anxious. His cardiogram is first reviewed. It shows normal sinus rhythm with a rate of 86 bpm. He relates that the pain started the day before and seems to be a little worse on inspiration. He has been pain-free since being placed in the cardiac room. He has no risk factors for heart disease and no prior chest pain or respiratory problems. He has no significant medical history or history of anxiety disorder. He appears to be in good physical shape and runs regularly. He feels he may have strained a calf muscle running a few days ago. On examination, his cardiovascular and respiratory examinations are normal. His heart rate and respiratory rate are now both normal at 78 and 18, respectively. He has some localizing pain at the insertion of his left Achilles tendon, but the calf is supple with no pain on deep palpation. The EP reads his chest x-ray as normal. He reassures Brad that all seems fine and if his troponin is normal he can probably go home. Brad's wife is concerned about an elevated test result that was mentioned to her by the nurse. The EP tells her he will check

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the bloodwork and return shortly. He finds the nurse as soon as he leaves the room. She immediately asks him if he has seen the Ddimer result. She added the test to the bloodwork because she had a strong intuition this might be a PE. She had seen two cases of PE the previous week. The D-dimer was 350 (in this laboratory, threshold is 200 for a positive test), and the patient's troponin level was